Health Insurance Problems: Finding And Fixing Them
A brief consumer guide to locating insurance problems. Authorization, claims, eligibility problems identified. Dealing with mental health and substance abuse carve-outs.
Ask anyone about insurance companies and they'll tell you they're usually difficult to work with. They keep you on hold, they delay payment of claims, and--most recently--they aggressively control costs using managed care, spending caps, and other measures. Often, when there's a problem, the sheer size and complexity of an insurance company can be intimidating. But a simple knowledge of the insurance industry and how its basic processes work can make the task of solving problems easier. At bottom, an insurance company provides a service to customers, and in general wants to keep their customers happy. Troubleshooting with an insurance company is time-consuming but not impossible. What follow are some guidelines and basic information that can help.
Find Out Where the Problem Is
The first thing you need to do is make sure you understand your benefit package. If you get insurance through an employer, you should have received a benefit summary from your Human Resources Department. If you purchase insurance by yourself, get it through another type of group, or simply don't wish to discuss insurance problems with your employer, you should, of course, start with the number on your insurance card.
Questions to Ask. Insurance company employees who deal with the public usually work with more than one type of benefit. Although they're supposed to know benefits thoroughly, some of these benefit structures can be confusing to them as well as to you. Confusion arises especially when there are carve-outs--i.e., when a particular type of benefit is managed by another company. Examples of carve-outs include prescription plans, mental health and substance abuse benefits, out-of-network benefits, and benefits for inpatient treatment or long-term care. If your claims problem is in an area that has been carved out, the problem may be due to poor communication between your doctor's office and the carve-out company. Finding out whether a benefit is a carve-out will get you to the right person more quickly and help you avoid delays in getting answers.
Parts of the Insurance Industry. Most insurance problems have to do with one of three areas in the industry: eligibility, authorization, and claims. The first is a "yes or no" question: either you were eligible at the time of service, or you weren't. If you're no longer employed at the company and using Cobra, problems can arise if there was a delay between the time your Cobra plan administrator received a Cobra payment and the time it was posted to the insurance company.
Authorization is another area where problems can frequently arise. Companies require authorization at various times and for different procedures. One of the most common is for the insurance company to require that your primary care physician provide a referral before it authorizes a visit to a specialist. Or, to access mental health and substance abuse benefits, you may be asked to call a special phone number and speak with a social worker or chemical dependency counselor, either on the phone or in person.
Many people find the authorization process intimidating and intrusive. However, in many ways it makes sense. If you call an investment brokerage asking to make a particular investment, many firms are required by law to ask questions about your financial picture, to determine if the investment is right for you. Even some auto mechanics are required to run diagnostic tests on your car before replacing any parts or doing any expensive repair work. Why shouldn't similar rules apply, then, to your physical and mental health?
Authorization problems can arise, however, if the insurance company receives the referral form after the specialist's claim. Or, the type of mental health or substance abuse treatment you want may not meet the insurance company's definition of "medical necessity". In these cases, you can appeal. If it's an emergency and you believe the treatment is a matter of life and death, do the treatment first. You can always fight the company later, either through their internal appeals process or in court.
Claims are the third most frequent area where problems arise. Some of the most common problems are: the doctor's or hospital's billing office sent a claim to the wrong address, used the wrong procedure, diagnosis, or revenue code, or billed for services that should have been included as part of the doctor's contract with the managed care company.
What to Do
Have all your information ready, especially dates of service, if you're contesting a claim. Never make equivocal statements such as "I think I saw the doctor in March, but it might have been April"--you'll be asked to call back when you have all the facts. Speak firmly but politely. Make sure you get names and, where possible, extension numbers of people that you speak with. Never give more information than requested. Remember that insurance companies are big and often difficult to navigate--believe it or not, even for some of their employees! If a person doesn't have the information or can't provide the commitments you want, a useful phrase is, "If you can't help me with this, please connect me with someone who can."
Handling insurance problems can be time-consuming and often frustrating. However, finding out where the problem lies is a major step to solving it. Speaking with the right person is important also. Once the company finds out what's causing the problem they are obligated, as a company that provides a service to customers, to correct it.