About once a year now, I have some major fight with a provider over my insurance coverage and how they’ve done something wrong, and then I share about it here so that others know to be more cognizant of their billings. Here’s two quick ones, and I have a lengthier one that I’ve been working since November 2021 that I’ll share separately. I have a post that goes into the details of reading your insurance benefits, so this will just be the stories of what went wrong and how it got resolved.
On May 17, 2022, I received an email from my doctor that said:
We have recently learned that several insurance companies … have sent inaccurate information that [we are] now out of network for their members. This is not the case and is incorrect information. We currently are in network … and we remain in network with all the same insurance companies we have been contracted with since 2021. If you receive a letter like this from your insurance company and have questions, please call our Patient Services team.
About a month after this email was sent, I received a statement for an obstetric appointment that said I owe $330, even though maternity benefits should be covered in full for routine care. It said it applied to my deductible, so I was really confused because we met that in January. I finally saw that it said it applied to my out of network deductible. I called the 800 number they gave in the email, and the woman who answered acted like she had never heard of such an issue with the insurance.
Since she was no help, I called my insurance directly. It took a few moments for that lady to get what I was saying – that you go to the doctor every 4 weeks, if not more often, when pregnant, and I’ve seen this provider both before and after this one claim, she had always been in network, so there’s a glitch. Thankfully, she could handle it for me. She worked with the provider to get the claim resubmitted and reanalyzed.
I made a couple of follow up calls and finally made real progress in February 2023, for a claim that was dated April 2022. Last week, I received an updated Explanation of Benefits that showed the claim was covered in full. My statement on my provider’s website still said I owed $330 yesterday. I called them, and they were able to see that the updates were being processed; sure enough, today my balance is listed as $0.
My dad went to the emergency room. They ran some tests and then observed him for a few hours before allowing him to go home. He received a bill from the hospital that said insurance denied the claim because it was for observation. He called the insurance company. The lady who answered never actually listened to what he was saying. She assumed he was wrong and misinformed, and she just kept talking over him.
First she told him that it wasn’t covered because it was in-patient and out of network. When he pushed back, she told him that it was covered, but it’s two dates of service (on the in-patient concept). That’s actually not the first time I’ve dealt with that annoyance and an emergency room. Once, I went to the ER at 10 pm and was charged for two dates of service even though I was released from the ER around 5 am. My dad had gone to the ER around 7 pm and was released in the morning. When he pushed that even if they were seeing it as two dates of service, he’d be looking at $300 (two copays) and not $2200, she came up with another excuse. She said it wasn’t covered because it was observation care. He said “I walked into the emergency room. I hope I was being observed.” She never once said “it sounds like the provider didn’t code the billing correctly; let me look into it.”
My dad eventually hung up on her. Seriously, if you’re not being heard and they’re talking over you, try again with a different person. I’ve had some people answer the phone that are the sweetest and most helpful customer service workers, and I’ve had some that are completely the opposite as if it’s your fault this is their job.
He set it aside to deal with another time. Shortly after, he received a voicemail from this lady where her tone was completely different and she said they were going to look into the coding of his visit. A week later, he received a voicemail from the same person, who said they reviewed it and determined the billing was done incorrectly and it was fixed. Instead of owing $2200, he now owed his $150 copay.
It’s important to know what your coverage is, how your insurance applies to your deductible, and your payment responsibilities. Do not assume that the billing codes were done correctly or that the insurance read it correctly. Neither the provider’s office or the insurance are going to think that they’ve made a mistake, so it’s likely going to take some persistence to get your story across. Don’t be afraid to advocate for yourself.
One Dollar Allowance 