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Insurance Billing Problem
Old 12-20-2008, 04:11 PM   #1
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Insurance Billing Problem

My husband had a routine screening procedure this summer. His insurance company refuses to pay the claim for the procedure. He has talked to the insurance company twice. Although they agree the screening procedure is covered by his insurance, they are unable to provide any informaton on why the claim is not being paid. The last time he talked with the customer service representative, he was told the claim would be reviewed/resolved in 30 days. He heard nothing back from the insurance company. Meanwhile the bills from the service provider (for $3500) keep coming.

Does anyone have any suggestions for how to resolve this problem?
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Old 12-20-2008, 04:25 PM   #2
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I would find out how to contact whoever in your state regulates insurance companies.

This is what a state representive can be good for.

US Representitive / Senator - contact them when you are into round #2. ( and your local newspaper, tv reporters etc...)
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Old 12-20-2008, 04:28 PM   #3
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Does anyone have any suggestions for how to resolve this problem?
Next time that you call them ask to speak to a supervisor. Demand a clear concise answer to your Q. That is their job~ to answer Qs and to pay or reject claims. Demand that they provide you with a written explanation and a CC to the provider.
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Old 12-21-2008, 06:33 AM   #4
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Sorry to hear about your problem.

I'm curious: what kind of 'routine screening procedure' costs $3500? I can imagine some possibilities, but none really seem to fall into the $3500 category.

Good luck!
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Old 12-21-2008, 08:43 AM   #5
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Meanwhile the bills from the service provider (for $3500) keep coming.
I've had similar issues. Make sure the service provider is aware that you are working with the insurance company, and it is under review. Make sure they are documenting your calls (and you document as well who you spoke to and when). You will keep getting bills from the service provider since they seem to have it on an automatic billing cycle. Just call them every time you get one (and make sure they indeed have it on record that you called the last time).

This is a super pain in the *ss. It takes forever for insurance companies to appeal/do reviews.
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Old 12-21-2008, 09:39 AM   #6
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I echo SG's advice. Don't pay the provider but keep them informed. What does your EOB state as the reason they have rejected it?

Also, whenever I go for a routine procedure, including annual physicals, the provider contacts the insurance company and tells me how much my out of pocket is going to be. Did your provider do a similar insurance check beforehand?
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Old 12-21-2008, 10:11 AM   #7
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I suggest a letter to the Insurance Co Pres/CEO with a CC to your State Insurance Commissioner. Insurance companies must go through a "Market Conduct" exam every three years during which these kinds of practices are reviewed.
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Old 12-21-2008, 05:10 PM   #8
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I've found that:

1. Written complaints to insurance companies tend to receive greater attention than phone calls

2. Be sure to check with your doctor for the correct billing codes. I've had several claims denied because the billing code was something other that what the insurance contract covered, even though the procedure was correct. Once the doctor's office resubmitted the claims with expected billing codes, they went through and were paid.

Good Luck!
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Old 12-22-2008, 09:04 AM   #9
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Thanks to everyone for their suggestions and encouragement.

A phone call to the insurance company this morning revealed that they had approved payment of the claim, but forgot to tell my husband or the service provider. They promised to send my husband a letter about the approval of the claim. He made them call the service provider about the decision while he was still on the phone.
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Old 12-22-2008, 09:19 AM   #10
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Thanks to everyone for their suggestions and encouragement.

A phone call to the insurance company this morning revealed that they had approved payment of the claim, but forgot to tell my husband or the service provider. They promised to send my husband a letter about the approval of the claim. He made them call the service provider about the decision while he was still on the phone.
Pleased to hear that you got things sorted out.
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Old 12-22-2008, 09:51 AM   #11
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It would still be useful to report this claims payment delay to the Insurance Commissioners Office. Any patterns of claims delays would then lead to regulatory action sooner, benefiting other policyholders.
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Old 12-22-2008, 02:38 PM   #12
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Success. Nice going.
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