As a holistic financial planner, I regularly advise clients on insurance. But even before I became an advisor, I had lots of insurance experience. I started my professional life as a lawyer dealing with insurance claims and coverage. When I changed careers to work in the public sector, I earned the Associate in Risk Management designation and submitted dozens of Workers Compensation claims.
Despite this experience, I had remarkable difficulty with a claim for an eye exam and was billed $583 for a covered service. Even though I carefully searched out an in-network provider, I didn't realize they would refuse to submit the bill to the insurer and would wait more than eight months to send a bill directly to me. What did it take to resolve the claim favorably? About five months of persistence, starting with my first receiving that bill long after my exam.
Here are my suggestions for how you can advance your own health insurance claims.
Tip 1: Check the network, and check again
Before you schedule your visit, make sure that the provider is in-network. This is not always as straightforward as it sounds: just because a location is in-network doesn’t mean that all providers there are in-network. In my case, the insurer agreed the provider was in-network but was hung up on whether he was in-network at the location I had visited. (He was, but I had to provide this information to them several times.)
Ask your provider directly whether they will accept your insurance, and whether they will submit your claim to the insurer. If you are scheduling an expensive procedure, you may also want to speak to your insurer to verify how much will be covered.
Tip 2: Provide thorough details
If the provider won't submit the claim directly, you may need to call the insurer before your appointment to find out how to do so yourself. Be sure to include every detail they request on the claim form and attach any other information that may help them see they should pay you the benefit you're expecting.
Keep detailed notes of every conversation you have with the insurer: include the date and time of your call, the name of the person you spoke with, and the number at which you reached them. Be prepared to provide a written timeline of every contact to make clear to the insurer that you have diligently responded to their requests for information. The more diligent you are in tracking these details, the clearer it becomes that you are living up to your responsibilities.
Tip 3: Be persistent
If your insurer tells you something isn't covered, they could be wrong. And in my case, they eventually changed their mind. So, it pays to be persistent. Not only did I have to call numerous times and speak to more than a dozen people, but I also followed the insurer’s instructions to the letter to achieve what was, at first, an unsatisfactory outcome. I had to write to them explaining what happened, who gave me the instructions, and exactly when I spoke to them. This made the difference between their initial check of $15 and my eventual reimbursement of $533.
Tip 4: Be patient on the phone, but let them know it's not your first call
Of course, it's frustrating when you're following every instruction you've been given and your claim still hasn't been approved. When you speak with claims representatives, remember that the person you're speaking with likely didn't create the problem. And while it's true that they may be used to people yelling at them all day, it doesn't mean they like it.
Imagine how you'll stand out by being the one who is courteous to them. It might enlist them as your ally, and you never know whether the person you're speaking with is the one with the authority to approve your claim.
Tip 5: Decide if you want to go over their head
If you're not satisfied with how the claim is handled, you can file a complaint with your state's department of insurance. They likely will require you to first go through the insurer's internal appeal process. But after that, they can get involved to investigate whether the insurer is living up to its policy requirements.
In my case, I will be explaining my experience to the Ohio Department of Insurance. With my background, I'm not scared off by the process of documenting my claim and filing an appeal with the insurer. So, if it can be this difficult for me to get my promised coverage, how many other people must give up in frustration when they're dealing with a technical and confusing world like insurance?
Tip 6: Decide how far you are willing to fight
Of course, we all have to judge whether the cost in time and frustration is worth the possible return when trying to get an insurer to cover what you expect them to. While I am happy with the outcome and don’t regret it, the process as a whole likely cost me more than $533 of my time. It was worth it to me because I did not want the company to get away without living up to their obligations, but that won’t be the case for every person and every claim.
Remember that you don't have to accept the insurer's first response (or even the second). If your first appeal does not go well, decide how much time and energy you are willing to invest. Persistence can be rewarded, and you'll never know for sure unless you try. But be wary of the sunk cost mentality—just because you already put hours into the process doesn’t mean that you need to continue. And if you do decide to fight a result you believe is unjust, remember these tips to increase the chance of a favorable outcome.