Proof You Can Fight Your Insurance Company — and WIN!

by Travis Pizel · 18 comments

At first I thought it was junk, since I didn’t know why else a medical center in Florida would be sending me mail. After opening the envelope and finding myself staring at a bill for $54, it suddenly came back to me. When my family was on vacation in Florida at the end of April, my wife developed an itchy and painful rash above her left eye. After she suffered with the rash for a few days, we decided it was time to have it looked at.

We thought we’d done everything right, as we’d taken the following actions:

  • Called our insurance provider to obtain a list of nearby in-network providers
  • Made an appointment and ensured it was a diagnostic visit (not urgent care or ER services)
  • Verified with both the medical facility and our insurance provider that the service would be billed as an office visit to a primary care provider
  • Called our insurance provider to obtain a list of nearby in-network pharmacies
  • Made a follow up call to our insurance provider to ensure we’d done everything properly

How I Fought My Insurance Bill

Though we’d been assured there would be zero out-of-pocket costs as per the terms of our insurance coverage, here I was looking at a bill.

I immediately pulled out my insurance card and dialed the customer care number. I explained my situation to the representative, as well as the precautions we’d taken while in Florida. After reviewing my information, she agreed we shouldn’t have been charged coinsurance for an in-network diagnostic office visit.

She put a note in the file and sent it back for reprocessing. She said we’d receive a new explanation-of-benefits statement in the mail, which should indicate we didn’t owe anything. She also gave me her name, and said if I had any issues that I should call and ask for her directly.

After a few weeks, we received a new statement from our insurance company. I took a deep breath as I opened the letter, and thankfully, it reflected a new balance of zero dollars.

The wheels of health insurance may turn slowly — but with a little nudge, they do turn.

Have you ever questioned the outcome of a health insurance claim? How did it turn out for you?

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  • Michelle says:

    I find myself so overwhelmed when I call and ask insurance related questions-out of pocket, deductible, yearly max, etc etc etc. I almost need a medical term dictionary to understand what they are explaining to me.

    • kayjay71 says:

      that’s not good…the customer service department should be better at explaining that….granted not everyone is going to take the time to help explain things in normal terms…but someone should….not everyone has worked in the industry to know what to ask and what it means 🙂 you should have a summary plan description which should explain everything…and if they make it right should also include a glossary for terms that are not always self explanatory 🙂

      • It’s getting harder and harder to get that information, unfortunately. We used to get a nice thick book each and every year explaining the benefits of our plan. Now we get a link to a pdf online that has much less information. it seems sometimes that calling our provider is the only way to get any answers…..and you cross your fingers that you get someone that has a clue what they’re talking about. I know if I got you on the phone I’d get all the right info though, kayjay71. 🙂

        • kayjay71 says:

          feel free to call me with questions anytime! I’ll even tell you what to tell your insurance company and or doctors office!!

  • MomCents says:

    KayJay71 ~

    Oh trust me I bug the doctors office! I don’t just point the finger at the insurance providers…but the entire system.

  • kayjay71 says:

    While it can suck to deal with the insurance company remember they are only processing claims based on how the provider (AKA the doctors office) billed it to them…we don’t make up the coding or the procedure codes…your doctors office determines which codes to use when they send the claim to the insurance company. I just had to call on a bill I received for some lab work because the provider decided to balance bill me (they decided not only would they bill me what I owed…they also billed their contracted write off) they claimed they were under contract negotiations and had just gotten the correct info…crock of crap…we wouldn’t have paid the claim if they were still under negotations! yes…I work for the insurance company…LOL

    When in doubt-call-it never hurts…but remember the insurance company can’t change a claim…only the doctors office can do that. so my note to momcents…start bugging the doctors office…they’re billing it wrong!

    • True, KayJay71, but in my case all the coding was correct and it was indeed our insurance company that processed it incorrectly. There can be mistakes by either or both parties (the doctor’s office AND the insurance company). When a mistake happens, we have to pay attention to the coding, and then try to figure out which party made the mistake – which can take several frustrating phone calls!

  • David Ning says:

    We had a health insurance scare with the delivery of our second baby. For whatever reason, they couldn’t find my wife’s records when they submitted the charges and we end up getting a few bills totaling almost $10,000.

    It took my wife MONTHS of calling the hospitals, doctor’s offices and the insurance companies explaining and re-explaining the situation but luckily, she was able to straighten it out at the end.

    The whole insurance process is very inefficient. I wish we could come up with a better way than the current system!

  • MomCents says:

    ARG!!!! I’m going through this right now

    /BEGIN RANT /
    We pay these crazy premiums..then we have to do the job of the insurance company and decode their nonsense and errors / END RANT/

    My stories are similar:
    1. Switched ins providers during open season
    2. Notified DR at next routine visit
    3. Got billed anyway
    4. When asked why, determined it was because they billed the previous company
    5. They billed the new company…happy ending (savings over $300)

    Also, colon cancer runs in my husbands family (scary right), so even though he is 30-something…he has to get checked out every 2-3 years. This is supposed to be coded as PREVENTATIVE and covered at 100%. But since he is not 55 yet, they always mis-code it and I have to fight that battle. (Fortunately I always win)

    My latest (and ongoing battle) is when a Dr. who is supposedly out of network (even though I asked at time of service) who billed separately from what the insurance paid out. So, the way it was explained to me…INS paid “globally” but then this doctor billed separately. My question is….why billed twice? Since when is he out of network. That case is currently under review…but the specialist couldn’t give me a direct answer, so hopefully they find in my favor as well.

    • Great Rant, MomCents…it just seems like it shouldn’t be this hard, right? I once had to fight my insurance company regarding a visit I had for Plantar Faciitis. The doctor taped up my foot, and charged an extraordinary amount for tape and gauze. THEN, my insurance company labeled it as “Surgery” because it altered my body. Really???? I actually lost that battle, unfortunately. I think the slogan should be, “Insurance: always an adventure.”

      Thanks for stopping by!

      • MomCents says:

        Wow that stinks! Surgery for gauze tape?! How do they get away with this??
        My co-worker had insurance that was supposed to cover his wife’s pregnancy and delivery at 100%. When she had a C-section, they coded it as lab tests….what?! He fought that battle and won!

        Since I wrote my little rant yesterday, I found a got a bill for my husband that should have been covered by workman’s comp….here we go again!

  • Very cool Travis! We’ve had to deal with something like this before, not while on vacation though, with my wife. It was a pain to deal with and we weren’t very expectant of getting a decision in our favor but we did. You’re right though, they don’t tend to move the fastest but it’s nice to see something good every once in awhile. 🙂

    • Medical bills always boggle my mind, John. I go into the doctor, and then wait a month or two for the Explanation of Benefits. Then it takes another month to get the bill from the medical facility. In this case, they sent it back for processing which takes another month. By the time we’re all said and done we’re dealing with an office visit that took place MONTHS ago! Spin those wheels a little faster, huh??

      • David Ning says:

        The speed is one thing, but what gets me is to think of all the extra resources necessary because of the need to deal with the whole insurance process. Extra employees at the doctor’s office, and all the employees at the insurance company means that a good chunk of our bills goes to salaries and not the actual care!

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