Â Â by Trisha Torrey
Health insurers have lots of sneaky ways to deny insurance claims because, of course, the less they pay, the more money they get to keep. I got some good advice from professional patient advocate, speaker and radio-show host Trisha Torrey on what we consumers can do to help get coverage when the insurers are trying to wiggle out of their obligations…
Â Six Secrets to Get Your Health Insurance Company to Pay
Â 1. Be persistent. Health insurance representatives generally will speak as if their decisions come from policies that allow for no variation. What the companies donât want you to know is that sometimes when you get turned down by one representative, another may be more willing to give you the answer you want to hear.
Â Try this: If a claim is denied, itâs worth checking to see whether you get consistent answers from two different sources — perhaps call again to see if another representative makes the same decision and/or speak to someone with more authority.
Â 2. Get everything in writing to even out the playing field. Insurance companies are scrupulous about keeping copies of all medical paperwork and correspondence involving your care — including letters and e-mail correspondence. They also may record telephone conversations and, if there is a dispute about who said what and when, youâll do far better if youâve also kept careful records.
Â To play at the same level: Retain copies of all correspondence (paper and online) that you send and receive. Also keep a log of notes and details of all phone calls (date and time, the name of the person you spoke to, what you discussed, any verbal commitments, etc.). And never accept only a verbal commitment from an insurance company — always ask for confirmation in writing.
Â 3. If you had no choice, you had no choice. If you werenât able to choose who your provider was, you should not have to pay higher, out-of-network costs.
Â For example: When your in-network surgeon chooses to use an out-of-network anesthesiologist for your surgery… or sends you to an out-of-network lab for blood work… the choice of provider was out of your control.
Â What to do: Insurers may do their best to deny the top level of reimbursement, but Torrey says to be persistent in stating your case and insisting on coverage. Similarly, when emergency care is needed and you are therefore not in control of health-care decisions, you may not be liable for higher out-of-network costs. Check your policy. Also, in some states, out-of-network emergency care coverage is mandated by law.
Â 4. Tell all… thereâs no such thing as too much information. Requirements are tightening up for screening tests that look for signs of disease before symptoms develop, and some insurers limit the diagnostic tests theyâll cover, too. Check your policy to be sure.
Â To get around this: Be sure you clearly and specifically report the symptoms you are concerned about, even if theyâre embarrassing (for instance, for colonoscopy a change in bowel movements or traces of blood in your stool).
Â 5. Even an insurance company can be intimidated by credentials and titles. Irate consumers arenât very scary to big insurance companies… but doctors and congressional representatives can make them nervous. If coverage is initially denied to you for a test or other service, an explanatory call from your physician might get a different outcome.
Â A good strategy: On critical correspondence, copy your congressperson, state insurance commissioner or another state board that regulates health plans. You can find links to the regulatory entities in all 50 states at the Web site of the National Association of Insurance Commissioners & the Center for Insurance Policy and Research (www.naic.org — check “States & Jurisdiction Map”). That way, the insurer will have to answer to them for the decisions it makes.
Â 6. Patient advocates know what works… and insurers know it. Insurers are not fans of these persistent, well-informed third parties who can help slice through red tape and are good at negotiating favorable coverage and settlements.
Â How to find one: Start with a service you donât even have to pay for — the nonprofit Patient Advocate Foundation (www.patientadvocate.org or 800-532-5274), which provides free case-management services for people with serious diseases, such as cancer, and has lots of experience needling insurance companies. (Note: This organization is staffed by volunteers, so its phones often are busy. If you find that is the case, you can go directly to its “Request Patient Assistance with a Case Manager” form by clicking http://gallery.patientadvocate.org/requests/paf_cm_request.php.)
Â There are also for-profit patient advocate firms that employ nurses and other health-care professionals to argue cases on patientsâ behalf. They may charge as much as $150 to $200/hour — but for a big bill, it might be worth it. You can find patient advocates in your region at Torreyâs Web site, AdvoConnection.com, a directory of patient advocates.
Â As Torrey notes, insurers are a wily lot — but you can get real results by using these secrets to turn the tables on them and get the health coverage you need and deserve.
Trisha Torrey, patient advocate, syndicated newspaper columnist, radio talk-show host and national speaker based in upstate New York. She is author of You Bet Your Life! The 10 Mistakes Every Patient Makes (available February 2010). Visit her blog at EveryPatientsAdvocate.com/blog.