Your health insurance claims representative and your doctor disagree as to whether your medical expenses should be paid under your insurance policy.
You want the claim to be paid so:
- You can get well
- You can use your personal funds to pay other expenses
- You don’t have to deal with the paperwork or other follow-up
- You can use your time for more interesting or required activities
If you could have the perfect insurance situation, you would go to the doctor and the claim would be paid without any effort from you.
Your doctor wants to:
- Be paid promptly
- Avoid the financial and time costs of proper claims filing
- Practice medicine freely without micro-management
- Earn a comfortable, if not excellent living
If your doctor could have the perfect insurance situation, your treatment would require minimal time for visits, documentation and claims filing but still generate substantial income.
Your insurance company expects:
- To make a substantial profit
- To please its shareholders
- You to take advantage of opportunities to avoid paying for expenses from your own pocket
- Your doctor to file the required paperwork completely and accurately
- Adequate documentation on which to make sound decisions
If your insurance company could have the perfect insurance situation, you would not require treatment.
Whether or not any of the interests and expectations are accurate or justified, these are the influences on the insurance claims industry. We must acknowledge them if we intend to work with them. The good news is that there are some shared interests on which we can build. For example:
- You and your insurance company would both prefer you not need treatment. Only your doctor has a financial interest in you treating.
- You and your doctor both want the claims filing process to be simple.
- Your doctor and your insurance company both want to make money.
- All of you want to save the money you have.
Here are some suggestions to streamline the process:
- You can use your doctor’s visits wisely. If your insurance policy covers annual physical examinations, take advantage of these opportunities to build a relationship with your doctor and learn more about your body so you’ll know when you need an office visit, a trip to the emergency room or rest and home remedies.
- Your doctor’s office staff members can take the time to complete claims forms with the required information—the first time. Although claims forms vary based on the type of insurance that might cover your treatment, most of the forms are self-explanatory. If the person completing the form reads each field and responds carefully, there will be less need for follow-up telephone calls, correspondence or rejection notices.
- Your insurance company’s claims representatives can take the time to read the forms, request clarifying information and make fair decisions on the initial submissions. I work with insurance companies, their claims representatives and their policy holders. Like all of us, they are trying to juggle many responsibilities and they make mistakes when they are rushing to meet the demands of their supervisors. Unfortunately, this often results in more work because multiple corrections might be required after one error.
- Your doctor’s office staff members and insurance company claims representatives can speak to each other more often. We’ve all gotten in the habit of relying on technology for communicating, but a telephone call is still one of the most effective and efficient ways of resolving complex issues. In one call, you might resolve the instant issue, identify problems you weren’t aware of, and gain pertinent information regarding obstacles that might otherwise appear in the future.
- You can learn about the requirements of your insurance plan and use the appeals or grievance process. Before you make an appointment to see your doctor, you must know whether you require pre-authorization for any treatment, tests, prescriptions, or referrals. Don’t assume everything will be covered by every plan. If you’re not sure, have questions or just want some peace of mind about your coverage, call your insurance carrier and make notes about the date, time, person, and discussion during that call. If your claim is denied, there are several sample appeal letters online that you can use to challenge the determination. See www.insure.com.
Plan. Act. Revise. Repeat. Read your policy. Follow the guidelines. If you, your doctor or your insurance claims representative makes a mistake, accept the human fallibility in all of us. Rather than wasting your energy on blame, focus on learning how the error happened and how to correct it. Take new action as necessary to reach the result you want. If necessary after taking corrective action, speak to a health care advocate or an attorney.
DISCLAIMER: This post is provided for general information only. If you have a specific insurance issue that is not being properly addressed by your insurance carrier and you have been unable to resolve it, please contact a health care advocate or attorney to discuss the specific circumstances of your situation.
Nance L. Schick, Esq. is a New York City attorney and mediator who focuses on keeping people out of court and building their conflict resolution skills, especially in business and employment disputes. Her holistic, integrative approach to conflict resolution draws from her experience as a human resources supervisor and minor league sports agent. She is a 2001 graduate of the State University of New York Buffalo Law School trained in Alternative Dispute Resolution (ADR) by the Equal Employment Opportunity Commission (EEOC). She is also creator of the Third Ear Conflict Resolution process.