How do I make dealing with health insurance companies easier?
January 26, 2014 2:37 PM   Subscribe

I see two medical providers on a frequent (weekly to monthly) basis. Neither provider accepts insurance. This means that to receive reimbursement I have to mail invoices manually to my health insurance carrier. The process is very difficult to manage. Please help me.

Getting reimbursed on my self-submitted claims is quite frustrating. For any given claim, in my experience, it is more likely that it will be rejected than paid upon first submission. The carrier will reject for reasons that are often trivial and poorly explained, requiring multiple calls. It's not unusual for a claim to have to be submitted and rejected multiple times before it is finally paid out.

As you can imagine, the above can get very difficult when you consider that you end up having to keep track of multiple batches of claims for multiple health care providers. It's enough to make you stop seeking reimbursement altogether, which is what has happened to me. I'm trying to get back on top of things though. I'm hoping you guys might be able to help. I'm looking for ways to keep track of everything and to reduce the time/mental burden that seeking reimbursement imposes.

Additional items to note:
-This isn't carrier specific. I've had the same problems with both Cigna and UHC.
-Mental health related, and located in NYC, where most good therapists do not accept insurance.
posted by prunes to Health & Fitness (9 answers total) 6 users marked this as a favorite
1. Document everything. I keep an Excel file with two spreadsheets: One, a running list of every phone call, received letter, doctor's appointment, etc., with columns for the company, date, reference number, etc. Two, a running list of "unresolved" issues that have notes for where I am in the process and what I'm waiting for (i.e. "Still waiting for document from XYZ company, supposed to receive 1/20.")

2. Always assume that the insurance company is incompetent, that they will work against you and that it will not be resolved easily. This sounds silly and overly pessimistic but I've found it helps me. I kept getting emotional and upset when I'd learn that the nice person I talked to at the insurance company didn't do the thing she promised to do, or when I'd call back and a different agent would say something completely opposite. It's a broken system, but recognizing it as such, and not expecting otherwise, has helped me a great deal.

3. Always get a reference number every time you talk to anyone. Always send via registered mail. Make photocopies of everything and take extensive notes of your calls. See No. 2. Always, always, always.

4. Set aside a time once a week to go over your Excel file and check in on the outstanding issues. Don't wait until your bills pile up or you're just in the mood. If you keep No. 2 in mind, you can just see this as a mindless exercise that is necessary but doesn't take much of your mental energy. Promise yourself something fun after you do it, like tea or a walk.

5. If you get frustrated on the phone with the insurance company, it helps me to think that I'm not talking to a human, I'm talking to an illogical computer to whom I just need to recite the correct phrase. It's my job to figure out the phrase. And really, the people who work there are basically forced to be computers, so it's not far off from reality.

Good luck... and know that you are definitely not alone in this. Props for getting back on top of things.
posted by rogerrogerwhatsyourrvectorvicto at 3:09 PM on January 26, 2014 [2 favorites]

I work for an insurance company and have actually helped quite a few people through this before. There are a few things that you want to absolutely have on the submission.

1) CPT codes (codes identifying the procedure performed)
2) Diagnosis codes (generally ICD codes or DSM codes)
3) Professional information (include name, address, tax identification number and provider credentials (i.e. LCSW, PhD, etc.)
4) Date of service
5) Billed amount (specific to each of the procedures performed. You don't want to have multiple procedures combined in one charge.)

If they will supply you with it, ask if they will give you a HCFA 1500 form. That will have everything you need for it.

Also, depending on the insurance company, you could possibly ask them if they will give you a case manager. It isn't always an option when the provider is not contracted, but it is worth asking.
posted by slavlin at 3:13 PM on January 26, 2014 [3 favorites]

Oh, wow, do I ever relate to this! As I was reading your question, I was thinking that this must be related to mental health treatment. And sure enough . . ..

One way that I deal with this is by setting up folders on my computer, organized by provider, and then by the date when a claim is submitted. I scan everything -- the statements and invoices, the claim forms, and the EOBs (Explanation of Benefits) that I receive from the insurance carrier, into the appropriate folder.

I also set up a spreadsheet for each provider, with columns for the dates of treatment, payment information (e.g., check #, date, and amount), the date the claim was submitted, the date of the EOB, the amount reimbursed, the amount unreimbursed, and -- probably the most important, the Notes column, to keep track of whatever the problem is on a given claim. Some claims are reimbursed with no problem, and those are checked off in a "done" column (the first column on the sheet). But for the ones that are problematical, the Notes section has brief entries of all my phone conversations with insurance reps, or other pertinent information. That way I can see at a glance whether a particular claim has been reimbursed and if not, why not, and what is the status of my efforts to follow through.

Wow, reading what I just wrote sounds like my process is exhausting, but I try hard to just make it routine, and having all the information easily accessible is essential to dealing with mental health coverage.

Okay, as I am typing this, I see someone else, rogerrogerwhatsyourrvectorvicto, has responded in a similar vein. I'm glad to see I am not alone in taking the super-organized approach to this infuriating situation!

I want to write more about how to deal with problems by getting in touch with the right person, but I will save that for a later post in this thread. (It's dinner time here!)
posted by merejane at 3:18 PM on January 26, 2014

Merejane here, with a follow-up post.

First, please do not give up on seeking reimbursement. I completely understand that temptation, as getting reimbursment for mental health care, even when you have good coverage, can be a nightmare and a seeming exercise in futiltiy. But that is not a reason to give up -- on the contrary, I think it a reason to dig in. Even though I am not normally given to seeing conspiracies in other areas of life, I sometimes suspect that insurance companies do have a policy -- likely unwritten, but very real -- of making it as difficult as humanly possible for claimants to obtain reimbursement, in the hopes that we will all just plain give up. Either that, or their employees receive almost no training. I find that pretty much every rep I have ever spoken with is pleasant and kind, but I too have had the maddening experience that every phone call nets a different and contradictory answer from the previous call, and that nothing gets done. (Claims are forever being "sent back," and I am assured the issue will be resolved "in a couple weeks." So I call back in a couple weeks, and find I am back at square one. This process can go on for months.) But whether it's a conspiracy to obstruct legitimate claims or just incompetence and poor training, this experience actually makes me more determined to persist. It is just not right that the insurance company can prevent people from obtaining reimbursement on legitimate claims.

Okay, rant over. Now on to what to do: beyond being organized and persistent, it can help enormously to contact outside agencies for help. I have done this on a couple occasions, with great success.

I live in New York State. For one group of particularly problematical claims, I contacted the NYS Attorney General's Health Care Bureau in Albany. An advocate was assigned to my case. I was also put in touch with someone in the insurance company's Appeals & Compliance Bureau. That person has been amazing, and now that I have her name and phone number, I contact her pretty much whenever I have a problem. I have to admit, she has really come through. It's still a pain, but it is no longer near-impossible to get claim problems resolved.

Another time, the insurance company denied an expensive claim for residential substance abuse treatment for a relative on our policy, on the grounds that a lower level of care (outpatient) would have been sufficient. That time, I had to go through two levels of internal appeals, which basically involved writing a (very long) letter each time. Not surprisingly, my appeals were denied. But New York State has a statute that provides for an independent external appeal to the New York State Department of Financial Services. (I believe the Affordable Care Act has a similar provision.) I filed an appeal with that agency, and I won! That win was worth about $30,000, and was very satisfying.

Because you are in NY, I will try to find some helpful links (to the AG's Health Care Bureau, and regarding the external appeal procedure), and post them later.
posted by merejane at 3:53 PM on January 26, 2014 [2 favorites]


NYS Attorney General's Health Care Bureau Complaint Form

NYS Department of Financial Services (scroll down to section titled "Health Insurance Complaints & External Appeals").
posted by merejane at 4:45 PM on January 26, 2014

Since you mention needing to catch up on your claims, I just wanted to mention a situation one of my doctor's offices ran into submitting claims to my insurance company, in case you haven't run into this yet: the insurance company repeatedly rejected claims for the sorts of trivial reasons you mention, but then after 180 days or some limit like that they simply said they didn't have to pay because of a clause in their contract with the doctor's office.

In my case I think the doctor's office actually gave up and ate the cost, but I wouldn't be surprised if they might try to pull the same thing on you.
posted by XMLicious at 6:01 PM on January 26, 2014 [1 favorite]

Merejane here again. The situation that XMLicious brings up reminds me that I wanted to point out that if a claim is actually denied (as opposed to being held up, with no decision one way or the other), there is a time limit for an appeal. I think it might be 180 days, so I wonder if that's what happened with XMLicious's doctor. But with claims I submit, it would be up to me to appeal, not the doctor, so I wonder if XMLicious's doctor was a participating provider?

Another problem that I have run into is that the insurance company just does not process the claim, and so there is no decision to appeal. But they can't sit on a claim forever. In NYS, there is a Prompt Payment Law. In fact, that's another column in my Excel spreadsheet: the date by which the insurance company needs to respond to a claim. If they ever miss that date, I would contact the AG's Office.

I'll look up the Prompt Payment Law link later and post it.
posted by merejane at 6:22 PM on January 26, 2014

How many different ways do the carriers have for you to submit a claim? Have you tried them all?

My carrier has this "EZ-claim" form where if you submit it on the website, it goes to one place (rejection and telephone hell) and if you submit via email, it goes to a different place (the auto approve). I found this much by accident but it is a happy coincidence.

Also if you haven't read your policy in detail please do read it. You may need pre-approval, etc that goes on special paperwork with signatures. I have seen this more with dental than mental health but reading your coverage, in detail, really helps. Also I have had odd requirements for doctor's orders, etc to get certain items approved. If your plan requires documentation for a visit to be approved submit it with every claim.

Finally your carrier might have an email address for the plan administrator. You might be able to email this person before you make a claim, asking for limits of coverage, documentation requirements, best way to submit in general terms for your provider. My plan has this and it has been key to proactively finding arcane documentation requirements and smooth approvals.
posted by crazycanuck at 7:02 PM on January 26, 2014

NYS Prompt Payment Law pdf (download).
posted by merejane at 7:38 PM on January 26, 2014

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