Health Insurance Claims: Third Time’s the Charm

Imagine: You’ve just returned home after successful surgery.  The adrenalin that coursed through your system to support your body throughout this intense experience has now gone into hiding, leading you to the most important part of recovery: Rest.

Healing happens most quickly and successfully when you’re calm or can at least avoid stress. All is well until you put on your sweats and amble out to pick up your mail.

And there it is: The first of many letters from the medical center where you had your procedure – plus nearly identical correspondence from your surgeon and the anesthesiologist who put you blissfully into Never-Neverland.

Unfortunately, the content of these notices can almost send many recovering patients right back to the Emergency Room with shortness of breath or other symptoms of a heart attack. Today’s costs for even a routine procedure at many medical centers are simply off the charts.

Once you catch your breath, you put your reading glasses, carefully review these documents and discover your health insurance company has only paid 25% of your expenses.

How can that be? The staff at your physician’s office checked with your insurance carrier ahead of time and confirmed complete coverage of both the procedure and the hospitalization – except for incidentals.

I love the term “incidentals.” Most people understand what incidentals are when staying at a hotel, but have no idea what the word means in a two-night stay at a hospital. “Incidentals” in a health care facility could be anything from a box of tissues to normal over-the-counter medications needed during your stay.

According to a two-year study by NerdWallet, personal bankruptcies resulting from unpaid medical bills affect nearly 2 million people every year – making health care the No. 1 cause of such filings. Perhaps even more shocking, an estimated 10 million adults with year-round health insurance coverage will still accumulate medical bills that they can’t afford to pay off.

If you’re going to succeed in securing optimal coverage for your medical expenses, it helps to know all insurance companies are snail mail fanatics. They think nothing of sending you three to five letters a week following a procedure (which does little to help you maintain a recovery-rich environment of calm).

So, here’s my 3-Step Solution for dealing with all those insurance notices – calmly and successfully:

  1. Open every envelope from any insurance company received. Do not let them pile up unopened.
  2. Check to see if there’s a line at the top or bottom that reads “This Is Not a Bill.” These should all be placed in a separate file marked “Not Bills.”
  3. Do not pay any bills until you’ve contacted the insurance company at least three times.

I’m sure you’ve seen movies or news programs about health insurance companies refusing to pay for treatment. Some are a little sensational but, in my experience, most of the stories depicted contain far more truths than lies.

Although it’s hard to prove in a court of law, many insurance companies have a standing policy of denying coverage of medical center or physician reimbursements on the first request. The most common practice is to deny the claim and then state that the agent who answered a call from a patient client just didn’t understand the request.

So, your second call should be made after you’ve received all of your medical bills. This is also the time to call your physician’s office, ask for their accounting person and request written verification of everything submitted by their office to the insurance companies. Most employees who do billing for physicians know exactly what documents you need and are happy to fax or email them to you.

Important fact: Insurance companies keep track of how many times you’ve contacted them regarding your bill or statements and pay far more attention the third time.

Unless you’re on Medicare and have an excellent supplemental policy, you’ll most likely have to pay for some part of your medical stay out-of-pocket. Very few insurance companies cover 100% of medical procedures.

But you should never pay more than your policy actually requires, just because an insurance company is trying to avoid paying more than they absolutely have to.

If you have the opportunity to plan your medical procedure – meaning it’s not an emergency room – take all the time you need to discuss your options and expenses with your surgeon, your primary care physician and your insurance company to determine the best course of action.

Be Smart.  Be Healthy.  Be Well.

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Lee Ann Monfredini

Lee Ann Monfredini

Lee Ann Monfredini is the founder of 360Women and a life-long advocate of women’s issues, political activism, social volunteerism, organizational accountability and personal responsibility. A graduate of the University of San Francisco with a degree in Non-Profit Management, she’s not only served on the boards and executive teams of some of the most respected health organizations in the Bay Area, but built a successful second career as one of the most respected realtors in the market. She can be reached at leeann@360women.net.

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