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February 15, 2017

In the first installment of my insurance nightmare blog, I shared how I had paid an estimated out-of-pocket cost to my children’s surgical provider without questioning the amount. I also shared some tips on things to do before you sign on the dotted line, so to speak, that may help make you a more informed consumer. Now, nearly three weeks later, I’d like to pick up where we left off and share another leg of my journey.

The Saga Continues

On December 6, I called the provider’s office to get a status on my anticipated reimbursement. At that time, the billing clerk told me that neither insurance policy had been paid. I promptly contacted my ex-husband and asked him to investigate the insurance claims. He could see that claims had either been filed incorrectly and/or incompletely and in the incorrect order (secondary was billed as primary) and, therefore, denied.

I called the provider again and requested copies of what had been submitted to further investigate the lack of payments. I was still trying to be helpful and carry the burden of collecting what we pay for from the insurance company. I was faxed claims for both insurances dated November 11. These were incomplete and incorrect submissions. Again, we offered to assist the provider in submitting the claim. This offer was repeatedly met with arrogance, defensiveness, dismissiveness, and flat rejection of the help.

On December 13, an email from a representative of the primary insurance company stated that after the file was researched, it was determined that no claims were submitted as of that day. In extreme caution and fairness to the doctor’s office, we believe the claims were still incomplete and/or incorrectly submitted, not that they were not being submitted at all.

Between December 13 and December 27, my family members, the insurance companies, and the provider’s office exchanged phone calls and emails. On December 20, the secondary insurance received a claim (subsequently rejected) that still did not include the EOB provided by the primary, which would then shift the coverage balance to their policy. The primary insurance company had an account representative via telephone on or about December 27, who walked the provider’s billing clerk through the submission process. On December 29, they processed an EOB and check.

I’ll choose to wrap up here on this part of the series. As you can see, the insurance company isn’t the bad guy here. We have all heard horror stories about how an insurance company has denied coverage that should be covered, or they only paid a small part of the claim, and a patient received a bill that they believed should have been covered after the fact. Several factors could contribute to receiving a bill that you did not expect, and some of those are considered insurance fraud and should be reported to the Insurance Commissioner. However, you should also ensure that your provider acts in good faith and that the staff is properly trained. You should be your best advocate - especially if they take your money upfront.


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