Insurance - A Full Time Job

Although I don't draw a salary, get paid overtime, or accrue sick days, I feel like I have a full-time job on my hands. Managing my insurance takes time, organization, follow-up, memo-writing, scrutiny, and energy - sounds like I've found myself a job, don't you think?

It always amazes me how closely I have to check my explanation of benefits (EOB) to ensure that what is supposed to be covered is being covered. I've written somewhere in the neighborhood of a dozen appeal memos/letters in the last few years alone (and I'm not typically a "letter writer"), and that doesn't include all of the time spent on the phone or via email hashing out why this test wasn't covered, but that one was.

Thankfully, most of my appeals have had happy endings, and for that, I know that I'm getting my job done. I know my husband would give me an A+ performance review for the money I've saved persistently following up with the insurance company when they are in the wrong.

It's been to my advantage that my Lupus testing/prescriptions/etc follow somewhat of a pattern. For instance, every eight weeks (if not more often), my rheumatologist calls for the same blood/urinalysis tests, all of which are monitoring the activity of my disease. Each round of tests costs me somewhere between $25-$75, depending on where I am in my deductible payment. So when bills arrive in the mail from the laboratory in the $300-$400 range, I know something's up. Even a $100 bill is cause for alarm.

Just last year, I saved over $900 by double-checking the bills that arrived. You may think that there's no way I could have missed an over billing of $1000. But when the errant billings are spread out over 12 months, buried in dozens and dozens of insurance claims, it takes a little sleuthing (and patience) to make sure that each bill is correct.

Here's a list of my top five reasons that the insurance company mistakenly overbills me:

1) Someone in data entry types in the wrong code for the test I had done: This one is usually an easy fix. Many times the customer service representative can make the change right there on the phone (because they can see the obvious mistake), or a letter from me (along with doctor's notes from my appointment) can clarify the issue.

2) My doctor needs to further explain the test/appointment/procedure I had done: This has happened to me several times, and usually a call to my doctor (who then contacts the insurance company) does the trick. Just 2 months ago, I received a bill for $155 (for a first-time test at my dermatologist's office), and had I not been on my guard, I probably would have just paid it. Instead, I put on my negotiating hat, called up the insurance company, and found out that they just needed further clarification from the doctor's office as to what was done. Once that transpired, I owed a whopping $12.50. (Maybe it's time to ask for a raise!)

3) Change in insurance policy of which I was unaware: This one can be tricky, but if the insurance company fails to alert its members of a change to its preferred providers, for example, how are we to adjust? Here's a snippet of a letter I wrote appealing an issue of this sort:

To ensure efficient and cost-effective processing, I understand that it is now necessary to request that my doctor send my specimens to a Lab One facility until further notice, rather than the Quest facility that he currently uses for my laboratory services. I am happy to comply with the new requirement and understand that coverage changes do occur. However, that critical change in coverage was not provided or communicated to me, nor to the rest of your membership, prior to the administration of these tests. Had I been alerted that a change had taken place and informed of the steps necessary to have my tests processed as they have been in the past, I surely would have done so...The merger between the two companies (which caused the change in policy) clearly has its benefits, but it is imperative that you inform your members regarding such changes prior to putting them into effect. Otherwise, you are doing the patients you cover a grave disservice. In fact, you are severely handicapping them. I’m sure you’ll agree that is unacceptable.

And they did!

4) Wrong classification of a test, medication, or procedure: Many times, there is a misunderstanding as to the purpose of the test/med/procedure, and explaining the end result of a test or the usage of a medication can clear up the issue. For instance, maybe the insurance company doesn't typically cover test X, but because I have Lupus, and it's considered a "medical necessity", the test is a covered benefit. Usually, I've been able to talk through these issues myself, but it may be necessary to involve your doctor's office.

5) Patient Misinformation: Someone billed the wrong patient, the wrong insurance company, or the wrong ID number. This one, while is the easiest to solve, can be the easiest to miss. With all of those EOB's coming in, the bill may look very normal and customary, until you look up at the one line "patient id number" and it's not yours!

Take it from me, it pays to do your job well. I'd say the trip Johnny and I took to Nova Scotia last year was paid for in part due to my hard work and diligence. Maybe I DO get paid for vacation time!


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