Useful Information for Health Insurance Claims

Since my daughter was born with numerous health conditions, I've met many special parents in waiting rooms and other scenarios. Our conversations have often led to the frustrations that come when dealing with health insurance. Here is an outline about handling health insurance claims that came from my personal experience from working in the industry for seven years. If you would like further information, I also found this article and this article to be helpful.

1. Be knowledgeable. Know your policy and what it covers. If a significant procedure or treatment is anticipated, contact your provider beforehand to find out what is needed (pre-approval, authorization, co-payments, etc.) so there are no surprises and you can provide the information or documentation that is needed to ensure approval. In the case of insurance claims, knowledge really is power!


2. Coordinate your benefits. If you have multiple insurance carriers (i.e. you and your spouse carry insurance through your employers; Medicaid and personal health insurance) it is important to let each carrier know about the other carrier. This can avoid so much frustration for you, the insurance carrier, and the medical providers!


3. Document, document, document. Many times payment of insurance claims are denied or delayed because of missing or inaccurate data. To avoid this, be proactive and get yourself involved in the documentation your medical provider submits to the insurance company. Ask to see the claim form. Ensure all the patient information is correct. Ask your doctor to ensure the diagnosis (ICD-9) and procedure (CPT) codes are accurate. This can prevent so many problems! When documenting, it is usually best to use a general diagnosis rather than a specific one. For example, instead of the diagnosis of 'Down's Syndrome' it is better to use 'low muscle tone' in order to get approval for physical therapy visits. Get the physician involved as well. Trust me, it benefits them as much or more than you for the insurance company to pay the claim, and they usually understand what the insurance company is looking for , so get them to help you ensure accuracy of documentation.


4. Kill 'em with kindness. Trust me, I worked in the industry for quite some time, and the people who work in insurance deal with angry people on a regular basis. Anger doesn't really do the trick. If you really want them to listen and take action, be nice. Be calm. Explain your situation. Find out how you can help them help you. Let them know you appreciate their help. This does not mean you have to be a pushover or have to accept empty promises. If an insurance professional does not do what they tell you they will do, insist on talking to someone in management to ensure the task gets done. But always, always, kill 'em with kindness ..... it will work every time! (Well, almost every time, that is.)


5. Sometimes it will still come to the appeals process. Don't be afraid of the appeals process. Again, knowledge is power. When a company sends a denial, it is federally mandated that they include with that denial instructions should you choose to make an appeal. Make an appeal; there is a 40% chance your claim will ultimately get paid. Follow the instructions specifically. It is good to have the provisions of the policy the insurance company used to determine denial. Read the exact policy wording, and work with your physician in determining the proper wording to use in your appeal letter and/or what documentation will support your claim for payment.
6. Negotiate with your provider. If the claim is ultimately denied, or if the co-payment causes financial hardships for your family, negotiate with the provider. Advise them of your particular situation and see if the charges can be discounted to an agreeable fee.

Before I decided to quit my job to be with my special needs daughter, I worked as a claims adjuster. I handled liability injury claims for auto and homeowner's policies, and worked in the industry for seven years. Although my prior employment does differ from handling the health insurance claim process and appeals process, I think I took away valuable knowledge in understanding what insurance companies are looking for and how to give it to them. If you have any specific problems or questions, feel free to make a comment about it or email me and I will provide any assistance or references I can!