May 13, 2009

Fighting with the Insurance Company

I've discussed this issue before, yet it seems to be a recurring problem. Until my daughters were born I could count on one hand the number of times I needed to call my health insurance company to question/dispute a claim. Since their birth... well, I lost track of the number of calls I've made.
For the first month after my daughters' birth, the hospital billed all their claims as "Baby A," "Baby B," "Baby C," and "Baby D," even though I named the girls the day they were born. So I spent months sorting out all the denied claims I received, all the while trying to convince the hospital to resubmit the claims with the girls' actual names. It took me until they were 1 1/2 to stop receiving bills from their birth.
Then this past January Hubby's employer switched its insurance carrier. The benefits are the same, but the service leaves a lot to be desired. Sue-Sue has a weekly physical therapy appointment to help with low-muscle tone issues. She receives this therapy through our local children's hospital, which is considered "in-network" by the insurance company. Yet every month I receive an explanation of benefits (and then a bill from the hospital) for hundreds of dollars because the therapy is incorrectly applied to Sue-Sue's deductible, rather than the straight co-pay we should be charged (which I pay at each appointment). Every month I call the insurance company, it's corrected and no one can tell me what the problem is. Yesterday I called to sort out the claims from April. The customer service representative actually said "I see you call about claims for Sue-Sue every month. Why is that?" Since I knew she wasn't responsible for taking care of the claims I simply laughed and said "I don't know. You tell me." First she tried to tell me that the hospital bills the therapy as an "outpatient" service rather than an "office" service, so she didn't know if the claims adjusters would even reconsider the claim. (WHAT??) Then she looked at our benefit terms and realized it didn't matter "where" the service took place as long as it was an in-network provider. She immediately transferred me to a claims adjuster who took care of the issue. This person told me he has no idea why the claims are being filed incorrectly, and warned me I should be prepared to call again next month.
I've always wondered what happens to the less informed in these situations. Certainly there are people who either a) don't know how to read an explanation of benefits, b) believe there is no way to dispute the explanation of benefits or c) simply don't read the forms and just pay what they're told. Taking care of my daughters' medical needs has taught me to read each and every form I receive and file them away for future reference.


Stephanie B said...

Ain't that the truth.

I question everything. It doesn't always go my way, but I've fixed a few things that should never have happened.

Not just for insurance either. I know what my children are being treated with and why or I change doctors.

Quadmama said...

Good point... if a doctor/provider, etc can't tell me WHY they're telling me to do something for my child then I tend to ask A LOT of questions.

MaryAnne said...

How frustrating. Reminds me of the time earlier this year when my MIL got a huge bill for surgery she had done 7 YEARS ago, because they decided they had undercharged her. Seems to me if it takes them seven years to figure that out it's their loss. They botched the surgery anyhow and she wound up with secondary surgery to correct it. She said she wouldn't pay and so far we haven't heard any more from them but who knows if it's the end of that saga...

shydub said...

Im glad our insurance was not like that when i gave birth with jake, we even recieved refund for our appointment to the pediatrician.

I got friendship chin tag for you in my blog quadmama, grab it when you are done with the laundry hehehe.

Quadmama said...

MaryAnne: Seven years ago??? We actually had a similar problem a year after our girls were born. The insurance company audited the hospital and decided they had overpaid and expected us to make up the difference. Fortunately at the time we had a secondary insurance to make up the difference but it was a huge pain trying to work it all out.
Shydub: A refund sounds nice! I'll be over to your blog to check out the tag soon.

LauraC said...

I can't even count the number of hours I have spent dealing with insurance and I only had two!

Actually, Alex's helmet (due to plagiocephaly from torticollis) experience almost did me in. My insurance denied the helmet claim and I spent hours and hours over months escalating up the chain. It ended in a committee hearing call I had to take while on vacation, with me yelling "premature twin A, torticollis, months of physical therapy!" They denied it.

Then 3 months go by and no bill ever comes from the hospital. I called the hospital and asked how much we owed. It was supposed to be $3000. They said since they were supposed to get pre-approval for the helmet and did not get it, they decided to write off the cost of the helmet and not charge me. Just like that, $3000 bill completely gone.

And the worst part of the story is that I told them they didn't get pre-approval bc we got denied and asked for treatment while we appealed. I said technically, we owed the money bc we asked for treatment that we knew had been denied. They had already written it off though and would not let us pay.

(Sorry for the long comment! But really, it is so much time I will never have back! Although I guess I made $3000 out of my efforts?)

Quadmama said...

It's ridiculous the hoops we have to jump through, whether it's for one child or four. Plus every time I call the insurance company to ask about whether something is covered they remind me I can go online. Hey, maybe you should just send me a packet in writing and I wouldn't have to waste so much time!

Kristi said...

When I had Max this past summer, the insurance company "forgot" to file and pay some of the claims from the hospital. We had a $1500 deductible which we paid to the doctor. We continued to get a bill from the hospital for almost the exact same amount and we had assumed for months that it had been paid. After 6 months, we received a letter threatening to turn us over to a collection agent. We had no idea what was going on. I got on the phone with the hospital only to find out that there was an outstanding bill. Luckily, the lady I spoke with was very nice and understood that it was an insurance mistake. She flagged our account accordingly and they waited patiently for another two months before the insurance company got their act together. We had to get my husband's employer company rep involved and she ended up threatening the insurance company with ending business with them because we were not the first people this had happened to. Actually, we were like the 5th people this had happened to and it's not a very big company.

Insurance companies - my nemesis! God help us if the government gets involved with this, too, we've all seen how well they can control things.

Quadmama said...

I'm always thankful that we HAVE health insurance... but sometimes you have to wonder why it's so complicated.

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