Insurance Claims – Industry Problem or Provider Calamity (Part 2)

In the first installment of my insurance nightmare blog, I shared how I had paid an estimated out of pocket cost to my children’s surgical provider without questioning the amount. I also shared some tips on things to do before you sign on the dotted line so to speak that may help make you a more informed consumer. Now I’d like to pick up where we left off, nearly three weeks later, and share another leg of my journey.

The Saga Continues

On December 6, I placed a call to the provider’s office to get a status on my anticipated reimbursement. At that time I was told by the billing clerk that neither insurance policy had paid. I promptly reached out to my ex-husband and asked him to look into the insurance claims. He was able to see that claims had either been filed incorrectly and/or incompletely, as well as in the incorrect order (secondary was billed as primary) and therefore denied. I called the provider again and requested copies of what had been submitted in order to further investigate the lack of payments. I was still trying to be helpful and carry the burden of collecting what we pay for from the insurance company. I was faxed claims for both insurances dated November 11. These were the incomplete and incorrect submissions. Again we offered to assist the provider in claim submission. This offer was repeatedly met with arrogance, defensiveness, dismissiveness and flat rejection of the help. On December 13, an email from a representative of the primary insurance company stated that after the file was researched it was determined that as of that day no claims were submitted. In extreme caution and fairness to the doctor’s office, we believe the claims were still being incompletely and/or incorrectly submitted, not that they were not being submitted at all.
Between December 13 and December 27 phone calls and emails were exchanged between my family members, the insurance companies and the provider’s office. On December 20 the secondary insurance received a claim (subsequently rejected) that still did not include the EOB provided by the primary which would then shift the coverage balance to their policy. The primary insurance had an account representative via telephone on or about December 27, walk the provider’s billing clerk through the submission process and on December 29 an EOB and check were processed by them.
I’ll choose to wrap up here on this part of the series. As you can see, the insurance company isn’t the bad guy here. We have all heard horror stories about how an insurance company has denied coverage that should be covered, or they only paid a small part of the claim and a patient received a bill that they believed should have been covered after the fact. Several factors could contribute to receiving a bill that you did not expect, and some of those are considered insurance fraud and should be reported to the Insurance Commissioner. However, you should also make sure that your provider is not only acting in good faith, but that the staff is properly trained. You should be your own best advocate – especially if they take your money upfront.