A true story...

Shortly before the holidays, I visited my gynecologist. The visit went as such visits usually go: breast and internal exams, PAP smear, conversation about any concerns I might have. Right before it was over, the doc asked if I wanted a mammogram. We chatted about it. I'm 37, and I wasn't sure if my insurance company would pay for it until I was 40 years old. We discussed my family history of cancer, which is quite extensive, and decided to go ahead with it. She wrote the script and I headed to the checkout area. She's part of the local hospital's faculty practice, so her office staff called the scheduling area and made an appointment for me. January 4th.

Between the appointment at my gynecologist's office and my mammogram appointment, my mother died of cancer. One more cancer in a long family history. I was nervous about the appointment, but everything went well. A week or two later, I get the results from my gynecologist - negative. Everything is OK, and now I have a clean baseline to refer to, just in case. Great, right?

A few more weeks go by, and I receive a bill in the mail for the mammogram - $281.00

My insurance denied the claim because I'm under 40. I should have expected this since, like most plans, they do not pay for routine mammograms in women under age 40. But this wasn't routine; it was specially ordered due to my extensive family history. The hospital coded it wrong! My next step is clear: I have to get the code changed to include my family history. I call the hospital billing department. They can't change the code without my doctor's permission. So I call my doctor. This is where things get bad...

The nurse that I speak with says that they can't help me because baseline mammograms are not recommended in women under age 40. "But the doctor and I talked about this. We agreed that my family history placed me at risk and that an early screening was appropriate." Now the bombshell: "Well, I'm looking at your chart right now and Dr So-and-So wrote that she didn't recommend early screening in your case and that the test was ordered at your request."

OK... two things:

First, since when does the patient order the doctor around? I don't recall putting a gun to her head. If she didn't think I needed the test, why did she agree to order it? But that's a topic for another time...

Second, why in the name of all that is right would a doctor - any doctor - write such a thing in someone's chart without making it clear to the patient that she was ordering the test against her better judgment?

The answer to the second question is easy: the doctor was covering herself, just in case the insurance company who employs her - and make no mistake about it, if your doctor is a participating provider, he or she is employed by the insurance company - wouldn't cause trouble for her later.

Bottom line: they wouldn't help me. The nurse felt horrible, but given what the doctor wrote, there was no way that she could go against it and help me.

Like so many other times, I had to help myself.

I contacted the insurance company and explained that my doctor wasn't being helpful; I would be taking on the challenge of the appeal myself. I got a name, extension number, and fax number so that I could contact the right person once I finished my research and wrote the letter.

Next, I began researching early screening. I combed the Internet for credible sources: medical journals, reputable organizations, government guidelines. I tried to anticipate their questions and objections: Why is early screening recommended? Who needs it? How did I fit into these categories?

I collected the data, read through it and highlighted the most dramatic numbers. I categorized the information and wrote the letter, quoting the most respected sources, making sure to clearly outline how I fell into the early screening category, and being as clear and succinct as possible. The final letter:


February 13, 2008

Claim number: 1X23456789 Member ID: XXX123456789
Patient name: Andrea Smith (spouse) Member name: Steven Smith

VIA FACSIMILE: (888) 123-4567
ATTN: Debbie, Medical Review

Dear Debbie:

Further to our conversation on February 8, 2008, I am writing regarding BCBS of South Carolina’s denial of claim number XXX123456789 on February 5, 2008. (Copy attached for your convenient reference)

The basis of this denial was that I do not meet the age criteria under my benefit plan for routine mammography benefits. However, due to my significant family history of breast and other cancers, there was ample reason to start screening early.

My maternal grandmother was diagnosed with breast cancer, and underwent a mastectomy with follow-up chemotherapy. Both my mother and maternal grandmother were diagnosed with cervical cancer in their mid-30s and underwent hysterectomies. Additionally, my father has had several cancers, beginning at age 21, involving the throat, thyroid, base of the tongue, and prostate. My paternal grandmother died of colon cancer. My maternal grandfather died in 1989 of lung cancer. Lung cancer also took my mother’s life just before Christmas 2007.

The American Cancer Society has found that having blood relatives with breast cancer significantly increases the chance of developing breast cancer. Additionally, the National Cancer Institute states the following in their “Genetics of Breast and Ovarian Cancer” Physician’s Data Query (PDQ) Summary:

“In cross-sectional studies of adult populations, 5% to 10% of women have a mother or sister with breast cancer, and about twice as many have either a first-degree relative or a second-degree relative with breast cancer. The risk conferred by a family history of breast cancer has been assessed in both case-control and cohort studies, using volunteer and population-based samples, with generally consistent results” and that “family characteristics that suggest hereditary breast and ovarian cancer predisposition include the following: two or more primary cancers in the same individual. These could be multiple primary cancers of the same type or primary cancer of different types.”

In light of my family history of breast and other cancers, I am requesting a review of this claim.


Sincerely,



No pleading, no emotion, no threats. Just simple, straightforward information from credible, verifiable sources.

On March 4, my phone rang. It was Debbie, informing me that my case had been reviewed, and payment was approved. I owed nothing.

Lessons to take from my experience:

- Don't panic! A first rejection is not necessarily a final rejection.

- Don't wait. Frustration and anger can be powerful fuels. Use the energy to drive yourself. My fury at my gynecologist got the job done - from rejection to approval - in less than a month.

- If you need help, ask for it. Call your doctor's office for advice. If they won't help you, call your insurance company. Find the person who is willing to help you with the process, like Debbie helped me.

- Go for the most credible sources. Don't use your friend as an example. How can the person reading your letter know you're not making it up? Use respected medical journals, medical associations, and - best of all - the insurance company's own guidelines.

Hello all!

We finally ditched our crummy cable connection and got DSL.

Effective immediately, my email address is:

kanga1102@bellsouth.net

Please update your address books ASAP - our account with Charter has been closed and those emails will probably start bouncing shortly.

Andrea

Look into Medicaid and other state programs. If you haven’t already done so, contact your local Medicaid office (check the blue pages in your phone book for listings) and make an appointment to speak with a social worker. Even if you think your family makes too much money to qualify for Medicaid, make the call and ask about waiver programs for the disabled. Most states have waiver programs that provide Medicaid coverage for children and adults with disabilities. Each state has different rules and different programs, but you may qualify for one of them. While you’re speaking to your social worker, ask about any other federal or state-run programs that you may qualify for. If you don’t ask, you may never find out!

An SMA mom in Georgia wrote: “We get the (amino acid diet, ed.) formula through the WIC program, not through insurance. All children in Georgia who have Medicaid (waiver or not) are eligible for WIC until the child is 5. I've found that few people know that… If we hadn't had a knowledgeable and creative nutritionist assigned to us through Babies Can't Wait, I'd never have known. Also loaner pools... we had a Tumble Forms TriStander from the Foundation for Medically Fragile Children.. There's an organization called FODAC here (Friends of Disabled Adults and Children, ed.) and they recondition DME and give (not loan) it to other families.”

Use the grapevine. One SMA mom said it so well that it needs no further elaboration:

“I've found resources mostly by running my mouth all the time about what's going on with us. A PT, OT or Speech therapist will know about an organization (or program)… like the program through Medicaid called GAPP (Georgia Pediatric Program, ed.) that provides private duty nursing for medically fragile kids. Then when I find an organization or program I tell everybody we come into contact with hoping it'll stick with somebody and they can share it with another family. At first, his PT and OT thought I was a little lonely and probably a bit crazed BUT I think they understand my methods now. I'm always catching the social worker in the hall and telling her about resources I've heard about or used. Sometimes I think it pays to get involved in local organizations not related directly to (your child’s disease, ed.), exchange information with parents from other worlds, make some friends locally.”

Apply for the Health Insurance Premium Payment Program (HIPP). If your child qualifies for Medicaid as a secondary insurance, you may qualify for the HIPP (Health Insurance Premium Payment) Program. Under this plan, you may qualify for reimbursement of your out-of-pocket expense for health insurance premiums, deductibles and coinsurance. While you’re calling your state’s Medicaid office to ask about their waiver programs, ask about HIPP too.

If you know of any resources in your home state and would like to share them, please leave them in the comments or email me at kpax@charter.net and I will create a list to be published on the FighterMom site at a later date.

I've been wrestling with how to post this, since the magazine I saw it in has some strict guidelines about how their material can be used, and they charge dearly for the privilege. However, I didn't see anywhere that said that there was a charge for linking to the article, so here:

http://www.managedhealthcareexecutive.com/...e/detail/462222

This article is written about Durable Medical Equipment from the point of view of managed care organizations (a type of insurance company), and I think it provides good insight into the way they think.

Some abbreviations that come up:

CMS - Centers for Medicare and Medicaid Services
DME - durable medical equipment
MCO - managed care organizations
MSA - Metropolitan Statistical Area

I'd love to start a discussion of the article. If you have any questions or comments, post them here and I'll answer them as quickly as I can.

Andrea

It is easy not to think about how much your insurance company is spending on your child’s behalf until they come back and tell you that you’ve reached your policy limits. Some plans have annual maximums, that is, there is a limit to the amount of money your company will spend per year on your child’s medical expenses. Some companies have overall limits, others limit the amount they will spend on a particular type of care or equipment (especially DME). Once you reach your annual limit, your company will not provide you with any further benefits until the next calendar year. While not all plans impose annual maximums, almost every insurance plan has a lifetime maximum. In other words, they will spend a certain amount of money on your child’s care, within the limits of your plan, over the course of his or her lifetime. If you exceed the lifetime maximum, you will receive no further benefits from that company.

Call your case manager or check your policy documents to see if your have annual limits on all or any part of your coverage (ask specifically about durable medical equipment, since this is an area where many companies place limits as well as one where your costs add up). Also ask about your lifetime maximum and whether that maximum applies per person or to your entire family together. Find out how close you are to reaching your maximums, both annual and lifetime. If you’re getting close to either limit, it’s time to look into secondary coverage and other resources. It’s also a good idea to look at the way you’ve been spending your insurance money. See if all of your expenses make sense, and see where you can save money. For example, if you’re going to be renting a machine for a long time, find out if you can make it a rent-to-purchase contract. That way, once the rental fees that you have paid add up to the purchase price of the equipment, the equipment will become your property. One drawback to this is that, when the equipment becomes your property, it also becomes your responsibility. The DME company is no longer required to check on it or do maintenance or repairs on it. Some companies offer service contracts on purchased equipment, but think carefully before agreeing to one. The cost of the contract may greatly outweigh the cost of hiring someone to repair equipment if it breaks. Also, some insurance companies will not reimburse you for service contracts and the costs will come out of your own pocket.

One SMA parent sums it up nicely: “You have to look at lifetime maximums; ours is one million, which sounds like a lot, but you have to look at your past and current situations. <Our daughter> also had several hospitalizations and air lifts, which were huge chunks out of that. I am starting to get stingy with our supplies and am cracking down on our home nurses to not toss things that are being replaced ‘just because it's been a while.’ That is all money off of the one million maximum. I would hate for <my husband> to have to change jobs to get a new insurance policy.”

You’ve been denied coverage, or the level of coverage you received was too low based on your insurance policy documents. You’ve checked the Explanation of Benefits (EOB): there were no obvious errors. You called the insurance company and were not satisfied with the outcome of that call. What next?

If you feel that a claim was erroneously denied, you can stage an appeal, a formal request for reconsideration based on information that you, or your doctor, will supply. This information can come in many forms, and from many sources. The information should be summed up in a document called a Letter of Medical Necessity (LMN).

The first step is always seeing if your doctor’s office will handle the appeal for you. Some will, some won’t. If they will – perfect!

Sending a prepared Letter of Medical Necessity. If you are sending an LMN that was prepared by your doctor’s office, make sure to enclose a short cover letter identifying the claim. Include the patient’s name, the name and ID number of the insured party, group number (if applicable), item requested and claim number if one has been assigned. An example cover letter:

Dear Mr./Ms. (Name):

In response to Your Insurance Company’s denial of 4/8/05 (please see attached), regarding the following claim:

Patient: Jane Public
Insured: John Q. Public (father)
Insured ID: 123-45-6789
Group #: 12345
Item: Wheelchair (be specific – include the make and model name/number)
Claim number: 98765

I am enclosing the requested letter of medical necessity from Dr. Smith, MD, of the Orthopedic Medicine Department of (hospital name). Please contact me immediately at (512) 555-1234 if further information is required.

Thank you.

Sincerely,

If your doctor’s office is unwilling or unable to find the time to do the research and write the LMN for you, you will need to do the work yourself. See if your doctor will be willing to sign a prepared Letter of Medical Necessity. If he/she will, you will need to write the letter from the doctor's point of view. Avoid phrases like "my daughter" or "my son" or anything else that identifies you as the author of the letter. If the doctor has not agreed to sign the letter, you can write it from your point of view and sign it yourself. Either way, the letter will need to explain why the item or therapy you are requesting is medically necessary for your child.

Writing an appeal letter on your own. Some appeals will be simple. You’d be surprised at some of the seemingly silly – and easily fixable - things that an insurance company will deny a claim over. Other appeals will be harder. For example, proving that an item is medically necessary takes research, time and energy. Whether you take on the challenge of an appeal by yourself or you seek help with the appeal, you will need to know the proper process and follow it exactly. Before you expend any energy on the appeal, call your case manager and make sure you understand the precise reason for the denial and what you need to provide to get the appeal processed and approved.

Try not to think of this as a hassle – treat it as an opportunity to educate your case manager and the insurance company about your child’s condition, and the various therapies and equipment that your child needs. The effort you make now may prevent another family from having to repeat the process later. This attitude shift might seem impossible to make, but it will help you keep your cool while you’re dealing with the company, and that is important. Facts and reason will win an appeal. Emotion will not.

One FighterMom says: The most ineffective thing you can do is try to appeal to their emotions - the person you spoke to can't very well go to their superiors and say "well, I had to give it to her - she cried.”

Here are some basic steps to follow:

a) Before you can begin the appeals process, you need to determine exactly why your claim was denied. If you have not already done so, call your case manager for more detailed information about the denial. Have the EOB in front of you when you call and take down the exact reason for the denial.

b) Gather as much information about the original claim as you can. If your doctor’s office provided the insurance company with a Letter of Medical Necessity (LMN) stating his/her exact reasoning for prescribing the equipment or therapy, try to get a copy. Knowing what the insurance company was already told can be helpful. If a formal LMN was not prepared, get the diagnosis code (also called an ICD-9 code) that was used to justify the application. Make sure that the item was coded correctly – if a single digit of this code is wrong, it may explain why the item was denied. If the ICD-9 code is wrong, call your doctor’s office immediately and have them revise the claim.

c) Do research. Visit the manufacturer’s website first. Many times their website will contain links to supportive journal articles; use these articles to persuade your insurance company to pay for the item. Search online medical journals for information about the item or procedure you are trying to get approved. If you don’t have Internet access, contact the manufacturer by phone. They are usually very helpful because, if insurance doesn’t cover their product, chances are it won’t sell at all. Try to find other families who have had the item approved and find out how they got it; you may be able to use another family’s LMN as the basis for yours.

Manufacturer’s guidelines, articles from medical journals, current research abstracts and detailed information about your child’s particular case are all good pieces of information to use to support your request

d) Write the letter. This is a serious situation and merits a serious tone. Be as straightforward and businesslike as you can. Make sure to include all of the information about the original claim as possible – patient name, insured’s name (this sometimes differs from the patient name – check the EOB to be sure), insured’s ID number, date of claim, etc. If you have a case manager, address the letter directly to them and make sure to mail it to them directly. Write out all of your reasons why their denial was incorrect, but stick to the subject. If they denied a piece of equipment because it is not medically necessary, for example, make sure that by the end of your letter, you have given several pieces of proof that the equipment is a generally accepted form of treatment for your child’s particular condition. It is also a good idea to point out what’s in it for them. Explaining to them that spending $1,000 on a preventative treatment now will save them $10,000 in hospital costs down the line may help. Remember, insurance companies are in business for one reason and one reason only: to make money. Because what they do is so sensitive, we tend to forget that. It's nothing personal, but it can feel that way sometimes. Just keep it impersonal - stick to the facts - and they will have a harder time rejecting your appeal.

Avoid using reasons that do not directly relate to the health and well being of your child. Many reasons that are valid from a moral, even a logical standpoint, such as avoiding caretaker injury from lifting your child or caretaker’s need for sleep do not generally have an effect on an insurance appeal and, in most cases, are specifically excluded from consideration by insurance policy documents.

e) Back it up with copies of supporting articles. If you are unable to provide actual copies of the articles that you are citing, provide enough information about the article so that your case manager can find the article for him/herself. A proper citation includes a list of authors, article title, journal name, journal issue, and page numbers.

f) Use their own words against them. Comb through your policy documents for anything that supports your claim. If you do not have your policy documents, try the company’s website. If your primary insurance is Medicaid or other state-funded insurance, try the homepage of the division of state government that administers the program (the name of this department varies from state to state).

g) If the insurance company sent a formal letter of denial, it wouldn't hurt to attach a copy of that as well. The less work the insurance company has to do, the quicker you'll get an answer. It helps to remember that there is a human being on the receiving end of your letter. Think "what else can I do to make their job easier." It won't hurt to help them out by providing all the info they need and prevent them having to dig through files to find information.

An example LMN format:

Date

To Whom It May Concern: (or, if you have a case manager, address it to them directly)

I am writing on behalf of my daughter, Jane A. Public, regarding An Insurance Company’s denial of claim number 456 on 07/06/2006. A copy of the denial is attached for your convenience.

The basis of this denial was that Pediatric Vivonex is considered a dietary supplement and is therefore not covered on our plan. However, in Jane’s case, Vivonex is a source food, not simply a supplement to a normal diet.

Jane suffers from Spinal Muscular Atrophy (SMA), a disorder of muscle and of fatty acid metabolism that requires a special diet to maintain optimal health. In addition to metabolic aberration associated with immobility, systemic illness, muscle denervation, and muscle atrophy, SMA patients have inborn metabolic abnormalities in mitochondrial fatty acid oxidation and carnitine metabolism that may increase the liver and kidney's production and excretion of dicarboxylic acids.

Harpey et al. felt that there was a significant improvement in strength and function for 13 patients treated with modified diets that provide high carbohydrate and elemental amino acids and small-chained polypeptides, such as Tolerex and Pediatric Vivonex (Novartis, Minneapolis). (1)

In light of the above evidence that Pediatric Vivonex will be used as a source food and not merely as supplemental nutrition in Jane’s case, I am requesting a review of this claim. Thank you for your consideration of this matter.

Sincerely,

John Q. Public

Member name: John Q. Public
Member# 123-45-6789
Group# 987654321

(1) Harpey JP, Charpentier C, Paturneau-Jonas M, Renault F Romero N, Fardeau M. Secondary metabolic defects in spinal muscular atrophy type II. Lancet 1990; 336: 629-630

Uncooperative doctor and no time to handle it alone? If taking care of your child does not allow you the time to do the research required to handle an appeal on your own, and your doctor’s office is not being helpful, there is other help available. I have been providing free, no-obligation insurance claim assistance to SMA families for nearly four years and have recently expanded my work to include the Fighter Mom community. If you have questions, simply reply to this journal entry or email me at kpax@charter.net. Please remember that I do this work on a volunteer basis, so I may not be available immediately, but I will get back to you as soon as possible.

You've received an Explanation of Benefits (EOB) from your insurance company and notice that they did not pay the entire bill. Before you panic...

Check the EOB for errors. Sometimes a misspelled name or incorrect diagnosis code is all it takes for a company to deny a claim. If you notice any errors, call the insurance company immediately to find out what needs to be done to submit a corrected claim.

Call the insurance company! No one likes calling their insurance company, but it is by far the easiest and fastest way to fix a problem. Many times, a problem can be cleared up in a single phone call.

Make sure to have the Explanation of Benefits with you so that you can refer to it easily. Also make sure to have a pen, paper, your insurance card and any other information about the claim (copy of the bill, pre-authorization number, etc) that will help the company identify the claim and help you get the information you need.

If you are unable to speak with your regular case manager, or if you do not have one yet, make sure to get the full name of the person you’re speaking with. Ask for the spelling so that you know you have it written down correctly; you may need to track them down later.

One of three things will happen during this phone call. Be prepared for all three options:

1) The insurance representative may simply say “Oh, that was our mistake! I’ll put this through again for you.” Not everything will be a fight. If this is the case, put the paperwork aside where you can access it easily when the EOB for the re-submission comes through. Check both EOBs and make sure that the total paid is correct. If it is, staple it all together and put it away. If it isn't, a second call to your case manager is in order.

2) You may actually owe the amount they claim. Some insurances have deductibles that you must meet before they’ll pay a dime. Others only cover a percentage of the fee; you are responsible for the remainder. Many plans require you to pay co-payments. It is easy to forget this at times, but one call to the insurance company will remind you of the limitations of your coverage.

If you actually do owe some money, do NOT send payment until the provider bills you. The bill will contain information (account number, etc) that you should include on your check to help them locate and properly credit your account. Send a payment without this information and you run the risk of having the payment applied incorrectly, which is a whole different headache. Once you are billed and submit payment, attach a copy of the bill along with payment information (date, check number, amount paid) to the bundle of papers relating to that claim and file it. Having the payment information together with the information about the original claim will make things easier if you intend to write off these expenses come tax time.

3) The insurance company will have another reason – for example, the item or procedure is "experimental” or “not medically necessary”– for denying the claim. If this is the case, you will need to gather information and make an appeal. Speak to your doctor’s office first. Some physicians will gladly write a revised Letter of Medical Necessity (the letter that your doctor writes to the insurance company explaining why your child requires a particular item). Others will be happy to sign an appeal letter that you or someone else has written. There is no need for you to spend time away from your child to research and write an appeal if your doctor will do it for you. (If you are handling the appeal on your own, next week's entry is for you!)

Do not get off the phone without getting a clear answer from someone whose name you have written down! If the person you are speaking to is unable to answer your question, tell them that you really need to have the question answered clearly and ask to speak to a supervisor. If the person becomes belligerent or argumentative, hang up and call back later. (If you wish to lodge a complaint against the first customer service agent, do it in writing. Taking out your bad mood on the next person you speak with might offend someone who would otherwise be helpful).

Sorry it’s been so long! I was busy with the SMA Family Gathering here in Greenville. We had about 40 people from as far away as New Jersey and Ohio. There were 7 SMA kids, their siblings and parents, some Angel families and even a few people whose only connection with SMA is their love of the kids and their volunteerism. It was a wonderful time. If anyone wants to see some photos, please let me know and I'll send you an invitation to view my Kodak Gallery.

But back to business!

Here are some quick accounting tips that have saved me lots of trouble over the years:

1) Whenever you pay a provider by check, be sure to use the memo line. If you’re paying in person on the date of service, a short note such as “office visit” or “CAT scan” will help you identify the payment later. When paying by mail, include your account number (or patient’s name if no account number is assigned) and the invoice number (or date of service if the invoice is not numbered) and be sure to enclose the payment stub to help the office identify and correctly apply your payment. In both cases, note the check number on your copy of the paperwork. That little extra step can save a lot of time later.

2) Do not pay a bill by mail unless you are sure that the amount you are being billed is correct. For example: if you saw the doctor and neglected to pay the co-payment at the office, they will bill you for it later. If you paid your co-payment at the office and the bill states that there is a balance due, check to make sure that all payments made by your insurance company (both primary and secondary, if you have it) have been properly credited (you’ll find these amounts on your EOBs). When in doubt, call your provider’s office. In many cases, invoices are automatically generated by their system and are mailed without being checked.

3) NEVER pay from a summary statement. Always wait for proper bill, describing the exact nature of the charge, before paying. A statement is an informational document, meant to show all of your account activity. It is not a bill and should not be treated as such. That doesn’t mean that it’s not important. Always review your statement for accuracy; make sure all charges are yours and that all payments you’ve sent in have been applied. You would be surprised at how easy it is for a provider to make a billing or payment application error. If you have questions about a charge on your statement, or if a payment you sent in is not showing up on your statement, call your provider’s office.

4) If you are being billed for the balance of a charge after you have paid your co-payment and your insurance (both primary and secondary) has paid its portion, call your insurance company to see if there is another reason why you might owe the provider money. Perhaps you’ve reached your annual maximum? Or maybe the doctor has stopped participating on your plan and did not inform you? But if your insurance company tells you that you do not owe anything, call your provider, explain the problem and have your account corrected.

My doctor won’t prescribe certain items because he insists that my insurance will not cover them. What can I do?

It is ridiculous for a provider to refuse to prescribe an item or therapy that will help your child just because he or she believes that your insurance company will not cover it. Your doctor isn’t your insurance company, and cannot say how they will respond to a particular claim. In some cases, the doctor assumes that because one company won’t pay for an item, no company will. Even if the company that sent that other patient’s denial is the same company that you use, individual policies vary. Unless your policy specifically excludes an item, treatment or service, you should make the effort. The worst thing that can happen is that you get denied.

Arguing with an insurance company takes time, energy and research. By brushing you off, your provider may be trying, consciously or unconsciously, to save himself a bit of work. If you feel that this is the case with your provider, you might want to offer to do some research or provide a prepared LMN for them to sign. If you do not feel comfortable doing such research on your own, contact me directly at kpax@charter.net and I will gladly help you.

If, after offering to do the work, your provider still refuses to prescribe something that you feel your child needs, you want to ask yourself if this is the doctor you want handling your child’s care.

A quick reminder: To help things run as smoothly as possible, make sure that your doctor has the correct insurance information on file. Whenever you receive an updated card, make sure to give them a copy. Something as simple as sending the claim to the wrong post office box or the wrong department at the insurance company will lead to a denial. If you have more than one insurance plan, make sure that they file with your secondary carrier if your primary insurer denies coverage.

This installment of Insurance 101 inspired by a series of questions from Sue O’Neill…


How carefully should we check the paperwork that comes through?

You should always check paperwork thoroughly. ALWAYS. Denials need to be addressed promptly if you wish to make an appeal. If other mistakes are found, you should act immediately. Over-billing and incorrect payments happen more often than you think, and many people don’t consider it a big deal unless they receive a bill. However, even if your insurance company pays the over-billed amount in full, you should always be concerned. Letting it slide will lead you to reach your annual and lifetime maximums faster. By the time those limits are reached, it’s too late to go back over years of billing to find errors.

Do we need to keep everything? ALL the Explanation of Benefits letters, ALL the Coverage Requests?

If you intend to deduct any expenses related to medical care when you file your taxes, or if you receive reimbursement of any kind, such as from a non-custodial parent or a trust fund, you should keep all paperwork. If you don’t do either of those things, there is no real need to keep paperwork once a claim is closed; that is, once you receive the statement from your insurance company showing what was billed and paid by insurance, checked to make sure the amounts are correct, and have paid whatever portion you owe the provider (co-payments, deductibles, etc). If an odd situation comes up where you need the paperwork, you can always obtain copies from the provider and insurance company.

However, you might want to consider the convenience of having paperwork on hand in case you need to refer back to it, especially if you have a troublesome provider. At the very least, keep all papers regarding disputed claims so you can refer back to handwritten notes, etc if necessary. I keep paperwork for at least a year, sometimes longer if my storage space allows. If you choose to hang on to paperwork for whatever reason, these are my suggestions:

Separate active claims, closed items and problems

I have a two-slot paper tray where I organize all my insurance papers. The top slot is my active file. Whenever I see a doctor, go to the hospital or for lab work, I keep the encounter form and receipt in this tray. Once the Explanation of Benefits (EOB) comes from the insurance company, I check the items and amounts billed. If it all checks out, I look at the amount I owe the provider. If that amount (usually a co-payment or deductible) has already been paid, I staple the entire bundle together and file it (if there are no errors, and you have no need for the papers for taxes or reimbursement, you may choose to toss it). Whenever I add something to a folder, I always put it at the front. That way, everything in the folder will naturally be organized by date. If I have to pull and item from a file, I make sure to replace it in its original spot to maintain proper date order.

The bottom tray is used for on-going issues, such as erroneous billing, disputes and appeals. Separating these from regular active items makes it easy to locate information when questions come up or when new papers come in. All communication with your insurance company – including your notes from any phone calls, all correspondence (letters, emails), statements, receipts, etc – that pertain to a disputed claim should be clipped together and kept in this tray until the matter is resolved. Once the issue is settled, staple the entire bundle together – down to the last sticky note! – and file it. You never know when you’ll need the information again.

Filing and proper storage

One of the first things I did when I took over the insurance and financial filing in my home was purchase a small, two-drawer filing cabinet. This small (about $50) expense has been one of the best investments I’ve made. Not only does it keep items orderly and accessible, it provides a level of security that a dining room tabletop lacks. It locks, which prevents my four-year-old son – or anyone else – from getting curious and rummaging around inside. Plus, while not rated as fireproof (those cabinets can be much more expensive), it will provide a certain amount of protection to the paperwork in case of fire.

Inside the cabinet there are several folders. There is one for insurance policy documents, like current provider directories and benefit enrollment forms. Another folder contains blank claim forms for use whenever we see a provider that is out of network and doesn’t file our insurance for us. And there are three other main folders, one for each member of my family. All claims stemming from each family member’s medical care are placed in the appropriate folder. In a case where you have a lot of dealings with a particular doctor, facility or vendor (a physical therapist or durable medical equipment supplier is a good example), I highly recommend making a separate folder for that provider.

If you do not have the space or money for a filing cabinet, an expanding accordion file is a cheaper, though much less durable, alternative. If you choose this method, buy one for each family member, plus one for each troublesome provider.