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Rights of Policyholders

HANDLING HEALTH INSURANCE BILLING PROBLEMS & CLAIMS DENIALS

     As a consumer, you may find yourself in the following scenario: Your family is covered by a health insurance policy obtained through your employer. Your spouse was hospitalized and required a surgery. You provided the hospital with all your insurance information and assume that everything will be taken care of by the insurance company. Two months later, you receive a bill from the hospital. The insurance did not pay the hospital costs. You are shocked because you are now being charged for $50,000.

      Insurance coverage for health care services is a complicated issue for most consumers and health care billing can be very confusing. You may find yourself receiving bills for services that should have been covered by insurance. With so many different HMOs, health insurers, and plans, it is difficult to determine which costs are covered by your plan. Every health plan has a different formula of co-pays, deductibles, out of pocket maximums, and exclusions.

     Make sure you document all your contacts with the health plan in writing. Keep a record of all phone calls, the date and time of the call, the number called, the person(s) you spoke with, and the matters discussed. Follow up the phone call with an e-mail (fax or regular mail are also good) confirming the details of your discussion, including a statement of the problem, and the actions taken (or promised) by said person. Writing is important as documentary evidence when you file an appeal or a lawsuit.

     The following questions can serve as guide to help you focus your inquiry:

1.  Are the billed services covered by your insurance?

Before contacting your insurance, read your policy. You are in a better position to protect your rights, dispute a bill or denial of claim when you understand the terms of your health insurance policy. All policies have specific exclusions, such as maternity care or job-related injuries, so check your policy to make sure the billed services are covered. If covered, verify that the correct billing code was used. Simple typos (errors in typing the code number) can result in you being charged for the wrong procedure or service.

2.  Do you have an annual deductible and/or out-of-pocket maximum? If so, did you satisfy the amounts?

Depending on the terms of your policy, you may have to pay for medical care until you satisfy the deductible for the year. If you already met the deductible, your insurer may pay a percentage of the costs, leaving you to pay the remainder. Each insurer and plan has different limits and terms, so it is important to understand your own policy and how your insurer defines these terms.

3.  Did the health care provider bill your insurance?

Do not automatically assume that the provider billed your insurance.  If you have not received an explanation of benefits (EOB) or similar statement from your health plan within a couple of weeks of the service, check with the provider.  Make sure they billed the correct health plan and that they have your correct information (your name, policy number, etc), and then follow-up with your health plan.   

4.  If your provider billed your plan, check with your plan to see whether they     received the claim and ask if it was paid or not.  If they denied the claim, ask why.

If the plan denied the claim, find out the basis for the denial.  If you disagree with your plan’s decision, ask about the plan’s appeal or internal review process.  For HMOs, the state agency that handles disputes is the Managed Health Care. For health insurance companies, it is the Department of Insurance.

5.  If the bill has been paid by the plan, contact the billing company.

Some health care providers handle billing in-house, while others use a third-party biller.  Payment made by the health plan may take time to be credited to your account, especially if the payment was received by the provider but not yet forwarded to the billing office. Contact directly the office that prepared the billing.  If payment has been made but not yet credited to your account, ask how long it usually takes and then make a follow-up.

6.  If you continue to receive bills for services that were already paid for by you   and/or your insurance:

     Contact the biller directly and find out your current balance. The bills may have been sent before any payments were received and applied to your account.

     Compare all relevant receipts, bills, and statements on your own. You can find the source of the discrepancy yourself by comparing the bill with the other documents. Gather your receipts, cancelled checks, statements from provider, and insurer’s explanation of benefits (EOB) and then compare.

     Check to see whether you were billed multiple times for the same service. Your health care provider may have provided a number of services at one appointment but billed them on separate statements. If you find yourself being double-billed, notify your provider. Send a written letter asking them to fix the discrepancy.

7.  Has your claim been denied? Should you pursue internal review or appeal with the health plan?

     If the denied claim is for a covered service and you think you have met your share of costs, call your plan’s customer service department and ask to discuss the denied claim. A few phone calls may resolve the situation, but if not, you’ll need to file a formal appeal or internal review with your health plan.

     There are time limits for filing an internal review or appeal.  All appeal papers should be filed together with copies of supporting documents – EOB forms, receipts, bills, and notes that support your case. Clearly state your name and ID numbers (policy number, group number, etc) on every page, and organize the paperwork in a clear manner. For future reference, keep in your own file copies of all documents you send to your plan. Send your appeal package by certified mail or by courier that has proof of delivery.

8.  Should you pursue independent review by state agencies?

If you disagree with the outcome of your plan’s internal review, you may file an appeal with the state’s regulatory agency. Most states require that you contact the insurance company first and may require you to complete the internal review process before they will take your complaint, so find out about the regulatory agency’s appeal process.

9.  Should you file a court action?

If you are unsatisfied with the outcome of the external review, you may be able to file your claim in a lawsuit. Contact an attorney with experience in insurance law to determine what your options are.

© Law Offices C. Joe Sayas, Jr.