Out-of-network claim reimbursement questions
February 8, 2019 4:21 PM   Subscribe

Is there any way I can get my insurance company to reimburse out-of-network claims if the deadline for service/submitting has passed? What about expired checks from previous approvals?

I went to an out-of-network mental health provider to get seen sooner because I was very depressed. I then had difficulty submitting these claims for reimbursement because I was very depressed. I submitted some of them last year and got way less than I expected and set everything aside to look into later, which I didn't do because I was very depressed. The one check I did get expired. I still have a batch of claims to submit. Some of them are past the deadline by now.

The health care is United though a private employer.

Do I have any hope of getting any of this money back? (Not including the ones I can still just submit normally.)
posted by unannihilated to Work & Money (6 answers total) 2 users marked this as a favorite
I think there is some hope, yes. The expired check I am most optimistic about -- you should be able to call and have it re-issued.

With regard to the claims that are past the deadline to submit for reimbursement, I think there is a small but real chance you can get some money. It will take hours of effort, though, so decide now how much it's worth to you. My approach would be to file the claims, ignoring the fact that you're past the deadline, then wait for your rejection. There is a small chance you'll simply get a reimbursement despite being past the deadline. If you get rejected, then you have claim ID numbers and can call the insurance company and very politely ask for special treatment. You might have to go several rounds at this stage of calling, re-submitting paperwork, getting rejected, calling again. Document everything and keep meticulous notes. At the end you might get some money, but you might get nothing.
posted by telegraph at 5:23 PM on February 8

There are some health insurance resources listed at the MeFi Wiki ThereIsHelp page, and you can try googling the name of your state or city and the phrase "community health worker" to find organizations that may be able to help answer your questions and provide assistance with the process.

You may be able to ask for a reasonable accommodation of an extension of the deadlines, due to the impact of your depression, and the MeFi Wiki Get A Lawyer page includes links to a variety of advocacy organizations that may be able to help you navigate the process and give you advice about how to address your specific situation.
posted by Little Dawn at 5:48 PM on February 8

Don't waste your time. And it would be a lot of time. Insurers minimize risk on out-of-network claims by capping the amount that they'll reimburse at a very low number. Like you're lucky to get even 1/3 back in reimbursement. Factor in being past the deadline. It's an easy "Nope" for the insurer. If the policy doesn't consider claims past a specified time frame and your past that time frame, they will not pay. Full stop. Best case scenario is that they mistakenly pay the claims and you get reimbursed maybe 1/3 your out-of-pocket. Then, when they catch their mistake in 6 months, they will try to collect it back. That's probably somewhere in the policy too - the right to collect back overpayments within a specific timeframe.

I was a Benefits Manager for several years. I frequently had to advocate for employees with the insurers. In a smaller company, you do that. The insurers would go to great lengths to deny claims. Not all insurers. I'm in the Mid-Atlantic and have had great experiences with the local BlueCross/BlueShield groups. But, yeah, most are kinda slimy. They do well financially when they pay out fewer claims.
posted by MissPitts at 6:53 PM on February 8

Insurers minimize risk on out-of-network claims by capping the amount that they'll reimburse at a very low number. Like you're lucky to get even 1/3 back in reimbursement.

I'm not sure I understand this. The policy says they'll pay X amount on out-of-network claims. Like 80% or something along those lines.
posted by unannihilated at 1:14 AM on February 9

I'm not sure I understand this. The policy says they'll pay X amount on out-of-network claims. Like 80% or something along those lines.

Based on my own experience navigating health insurance issues, I think there is a fair amount of justified cynicism about private health insurance providers, but I also think it is important to keep in mind that the answer is always 'no' if you don't ask.

An example of how requests for reasonable accommodations work are included in template letters from Disability Rights Oregon - while these do not specifically address health insurance policies, they are examples of the gist of how ADA protections can work. For example, the model letters at pages 19 and 20 (pdf at 27 and 28) request a modification of lease policies to allow more time to accommodate the impact of a disabling condition, and there is also a model letter for health care providers to document the medical condition at page 13 (pdf at 21).

These are general examples only, and not legal advice about what to do for your specific situation - I can only tell you that based on my recent experiences with requests for reasonable accommodations, I feel that the ADA is one of the least-recognized civil rights victories, so I encourage you to contact a nonprofit legal services provider in your jurisdiction for free help with assessing your situation and tailoring a request if warranted; you may be able to find the local equivalent of Disability Rights Oregon by googling the phrase "disability rights" and the name of your state, or by contacting the disability rights organizations listed at the Get a lawyer page.

In my experience, things can quickly change for the better when you have a valid basis for a reasonable accommodation, and it may circumvent the kinds of delays and deflection that create cynicism about rights to equal access to health care and health insurance. There are also government agencies that enforce civil rights and may be able to assist you, and local legal advice can help you determine all of your options and what may be the most effective action to quickly resolve your concerns.
posted by Little Dawn at 6:27 AM on February 9

Your policy may say that the insurer will cover 80% of out-of-network claims. But that 80% isn't a straightforward 80%, i.e., doc charges you $500, insurer pays $400, you pay $100. The insurer's 80% is based on what they would have paid an in-network provider for the same service, not what your provider actually charges you.

So, if the insurer's in-network provider is allowed to charge you $200 for the same services that the out-of-network provider charges $500 for, the insurer pays 80% of $200, which is $160. You pay the remaining $40 plus the balance. It's the 'plus the balance 'that surprises people who submit out-of-network claims. Your total cost in this out-of-network scenario is $340, not $100. Insurer pays 1/3 of the cost in this out-of-network example and you pay 2/3.

Before considering how much hassle you're willing to go through to get your claims paid, it's good to know the actual amount that you'll recoup in the best case scenario.
posted by MissPitts at 6:42 AM on February 9 [1 favorite]

« Older Alternative to Crooks and Liars? Also, a Canadian...   |   What cable do I need? Newer »

You are not logged in, either login or create an account to post comments