Help me deal with my health insurance company.

September 4, 2007 12:39 PM

I'm scared to talk to my health insurance company regarding a denied claim and further needed treatment.

I moved across state lines recently and decided it was a good time to find a regular doctor. Potential mistake #1: I did not notify the insurance company that I wanted to switch doctors (I haven't seen the one listed on my card in years). Mistake #2: I assumed routine physicals would be covered under my plan. Apparently not, since I received a notice saying that none of the charges were allowed. One of the charges was for an ultrasound. They found something suspicious on the ultrasound and I need to get an MRI to figure out what it is. (I'm definitely not pregnant, FYI.)

I am really quite naive when it comes to health insurance matters. I don't understand how all this stuff works. I'm not even sure what the difference is between an HMO and a PPO, or which one I have (it's CompcareBlue, and I have a group # on my card). I just know that all my charges up to now (mostly therapy) have been magically covered. Also, I am not the most assertive person when it comes to dealing with faceless corporations.

So, how do I find out whether the MRI will be covered? Do I tip them off that I could possibly have some serious health problems? Do I try to get the physical/ultrasound covered, or do I assume that because they said it's not allowed, it's a lost cause?

posted by desjardins to health & fitness (16 comments total)

I don't have much to offer you other than to say: Don't ever, ever let them know that you might be in anything other than peak health unless you absolutely must reveal that information.
posted by GilloD at 12:41 PM on September 4, 2007

Are you covered through work? If so, these are excellent questions for your HR administrator. Your plan should have a one-pager that breaks down what is and isn't covered. Basically, there are a few key things to keep in mind:

1) Is your physician in-network or out-of-network? Your OOP expenses may vary greatly depending on this.

2) Don't agree to any (non-emergency) medical procedures without discussing coverage with your doctor. He/she probably won't have a specific answer for your plan, but will have a good idea of what generally happens. Depending on your plan, some/most non-checkup procedures (e.g. an MRI) will require pre-approval from your plan and/or a referral from your PCP (Primary Care Physician) to a specialist. Some plans have explicit coverage (up to $X/year) for certain procedures.
posted by mkultra at 12:54 PM on September 4, 2007

You mentioned that you move across state lines recently. The first thing to do would be to figure out if you are still in your plan's service area. If you're part of an HMO (generally consisting of a small -- i.e., not nationwide -- service area and no out-of-network benefits), there's a chance that moving out of state means that you have no coverage for anything but emergencies. The fact that there's a doctor listed on your card probably means that you are in an HMO with a gatekeeper, necessitating you have a primary care physician. Your role as a consumer of healthcare in your location will be easier when you get a local primary care physician.

As to why your claim got denied, here's a non-inclusive list of why that could have happened:
-Plan does not cover routine physicals
-Doctor not in-network
-Lab not in-network
-Deductible not met
-No referral from your PCP

You're going to need to do a little bit more research about your plan's network and benefits before we can answer your question about claim appeals.
posted by MarkAnd at 12:54 PM on September 4, 2007

Before you go to ANY appointment, outside of your primary care doctor, call them and check that it is covered, and what treatments will be covered.

The easiest thing is to get all of your appointments through your primary care doctor's referral.
posted by k8t at 12:54 PM on September 4, 2007

And absolutely what GilloD said regarding tipping them off to any potential health issues.
posted by mkultra at 12:54 PM on September 4, 2007

First off, if you want to get better versed in health insurance terms and norms, here's a guide from MedlinePlus. Also, if your insurance is through your job, talk to your HR/benefit coordinator. They can help explain your specific policy to you, and since they don't work for the insurance company, you might be able to be more frank with them than with an insurance claims person.

Call your insurance company and ask them why the exam wasn't covered (and don't tell them what was found--I second GilloD on that). If it's because the doctor isn't on your plan, find out how to choose a doctor that is. If it's because they don't cover routine physicals, maybe you can make another appointment with your doctor (or another) -- not a routine visit, but a "hey i have these symptoms" visit. That might get you set up for the MRI to be paid for. (Depends on your coverage).

Make the argument that the visit should be covered, but you might need to be prepared to eat the bill if the doctor is off your plan or you have to pay a deductible first. Ugh, I hate this stuff.

If you have a PPO, you have to choose a doctor from your plan (or you have to pay a lot more for it), but you don't need referrals to see a specialist. If you have an HMO, you have to see your primary doctor first, always, to get a referral to a specialist.
posted by jessicak at 12:59 PM on September 4, 2007 [1 favorite]

just call them and ask why your claim was denied. it's possible that your new doctor is not in your network. make sure they have your new address--the problem may just be that you have moved. treat it as an administrative snafu--you're just getting information so you don't make the same mistake again.

(before you make the call, blue cross's website has a "doctor finder." you might want to check to see if the doctor is in your network before you even make the call. if the doctor is listed, you'll have some ammo.)

if your new doctor is not in your network, they probably won't cover the mri. find a doctor who is in your network. call that doctor's office. explain what has happened. have the out-of-network doctor send your medical records to the new doctor. tell the new doctor that the old doctor wanted to follow up with an mri. you might have to get a second exam, but a second opinion won't hurt.
posted by thinkingwoman at 12:59 PM on September 4, 2007

Just call and ask them to mail you a copy of your rules/regulations binder type material. Mine, through a different carrier, lists common procedures and whether they are covered, partially covered, not covered, covered but require paperwork in advance, etc. Do not ever, ever assume that logic, reason or compassion will motivate their answer to any request you make - it is a business contract for them, plain and simple. Read the book, complete steps accordingly.

My two-second guess is that everything was "magically" covered before because you were working through a Primary Care Physician you named ages ago. Everything is "magically" covered for me because I "magically" read the terms of the contract that require me to go to my "magic" primary care physician. If I show up at someone else's random door, well, magically, coverage can be denied based on that technicality. In my experience, sometimes they are willing to retroactively designate the provider as your primary care provider in this situation and then provide coverage for the care.

Here is some basic, basic information about understanding health insurance. Probably you should read it, since I think a basic knowledge of how your health insurance works - beyond the "magic" will alleviate your fear and put you in a much better bargaining position, besides saving you thousands of dollars in obtaining coverage for your care down the road. No offense, but denied bills and other expenses are really the price of not bothering to be informed about this stuff.
posted by bunnycup at 1:00 PM on September 4, 2007

Sorry, was so busy with my holier-than-thou attitude that I did not link the basic information.
posted by bunnycup at 1:03 PM on September 4, 2007

If you get the insurance through work, definitely talk to your benefits administrator and make sure you understand the plan you are on. Given what you said above, it sounds like your plan is an HMO that requires all medical care be coordinated through the a specific primary care doctor that you previously selected. BTW, the primary care docs in HMOs are often compensated partly on how few referrals they do to specialists. Just an FYI...

PPO's usually offer more flexibility in that you can normally go to any doctor in their network without needing approval. That said, expensive tests like MRIs often need to be cleared in advance. There is no logic to what is allowed and not allowed either. We've had insurance companies fight us on $100 charges while not blinking at a $2000 MRI the week before. It's madness, which is why it is critically important that you get educated about your plan and what other options you may have.
posted by COD at 1:05 PM on September 4, 2007

I guess I should have mentioned that this is a COBRA policy - I recently graduated from grad school and had my insurance through there (worked as a TA). I don't work there anymore so there's no HR department to go to.

bunnycup - point well taken, I accept the consequences of my ignorance, and that's what I'm trying to remedy here.
posted by desjardins at 1:18 PM on September 4, 2007

if you call the hr department where you used to work, they will still probably help you. but it might be more productive to call the insurance company directly.
posted by thinkingwoman at 1:27 PM on September 4, 2007

COBRA usually gives you the same benefits that you had before. Call the customer service number on the card and ask them to send you info. Also ask why it was denied. If you feel it was unjustly denied (once you know what's covered) you can appeal, and the info on how to do that should be on the denial Explanation of Benefits. I think you have to do it within a certain length of time after the denial, but I'm not sure.

Before your MRI, make sure not only that your doctor is in-network, but that the place you are having the MRI is in-network as well, whether it's a hospital or a free-standing MRI center.
posted by la petite marie at 1:32 PM on September 4, 2007

COBRA usually gives you the same benefits that you had before.

You get to be treated like a "similarly situated active employee." Unfortunately, if the employer has no provision for out-of-state employees, you might be out of luck. Universities sometimes have options for faculty or staff going on sabbaticals to out-of-area universities or whatever, but they often don't. Just to be clear, the OP's current insurance may well not cover anything but emergency services. I'm not trying to freak her out, but leaving the plan service area (if she did that -- I don't know the service area of the plan) is something that should have been reported to the plan administrator when it happened.

I'm with everyone else now: contact the HR department of the former employer.
posted by MarkAnd at 2:53 PM on September 4, 2007

Did you happen to move from Wisconsin by any chance? From looking at this CompcareBlue website plus knowing that this is a COBRA plan, I can see a number of potential issues right off the bat, any one of which might have led to the denial. These are all very common problems and you should be able to get the answers from CompcareBlue and/or the benefits rep at your former school pretty easily.

a. Provider Not in Network - CompcareBlue appears to be a Wisconsin-only network. It looks like you may have access to providers outside of Wisconsin through a network called the National BlueCard Program. If so, is your new doctor in that network? If there were lab charges for the ultrasound, is the lab in-network?

b. Requires Preauthorization - Some plans require preauthorization for labs and radiology such as ultrasounds and MRIs. Does yours? If so, did you have one done?

c. Procedure Not Covered - Many COBRA plans are only for catastrophic care and don't cover routine treatments like office visits. Is yours like this?

d. Deductible Not Paid - COBRAs are also notorious for having high deductibles. Have you met your deductible for the year?

e. Incorrect Information - According to the website, CompcareBlue is now doing business as Anthem Blue Cross and Blue Shield as of May 2006. Have you received any new insurance cards since then?

As far as next steps goes, first look at the Explanation of Benefits (EOB) you received stating that the charges weren't covered and find the reason for the denial. Call CompcareBlue if you're not sure. If it was for reasons (a) through (d) above, then the mistake is yours and you essentially just have to suck it up, pay the charges, and chalk it up to a learning experience. If it was (e) and you used an old card, you should be able to give the doctor's office the correct information and ask them to resubmit the claim.

Regardless of the outcome of this particular claim, if you can get a good understanding of your plan's requirements around each of those first four issues, you should be able to head off any problems with future claims.
posted by platinum at 4:02 PM on September 4, 2007

Well, for future searchers - this was a hard lesson learned. I am not covered for anything except emergencies, since I am out-of-network. I am very glad I called before going for the MRI. I would have been seriously financially ruined. As it stands, I'm only out $500 for the physical + ultrasound.

Fortunately, I live fairly close to the WI/Illinois border, so I can drive an hour or two and see a doctor that's in-network. With Chicagoland traffic such as it is, it's probably a shorter drive.
posted by desjardins at 8:16 AM on September 20, 2007