Doing Battle with Insurance Companies
Photo courtesy of furryscaly via Flickr
Many of us have been in the situation of having an insurance claim rejected. Often it can be solved by simple documentation. It’s a nuisance, but they go away quickly. In other situations, the insurance company digs in and is adamant that you shall not be covered. In some situations, they’re dead wrong and with a good deal of effort, you can prove it. In other situations, you’re either in a gray area, or totally in the wrong. In all cases, there’s a chance you can get the insurance company to pay.
Understanding your coverage
The first thing to do is to spend some time reviewing your coverage. In most cases, you probably received the detailed information on your insurance in the mail. They typically document policies on their sites. You don’t have to be a lawyer to understand most of it, thought it might help. You don’t have to read it all either, because there’s likely a section or two that cover your specific situation. Skim most of the document and mark and thoroughly read the parts that apply to the current issue.
Insurance call centers
People who manage call centers typically measure performance on things like, ‘first-call resolution’, number of calls handled by agent, agent availability and cost per call. Their motivation to solve customer situations quickly and efficiently can work for you and against you, depending on how difficult your situation is and how far apart you and the insurance company are on the claim. Don’t think that by wasting their time that you can badger them into submission. What you can do is use their motivation to satisfy your needs quickly to your advantage. Most call-center staff are trained on the ins and outs of the policies and procedures and they often have key reference materials at their fingertips. Ask questions about your coverage. If they’re denying you coverage for a specific claim, ask how this situation could be avoided in the future.
There are some specific techniques that will help you when engaging with the call center:
- Have paper and something to write with before starting the call.
- Take the name of the person you get on the phone. Some call centers allow you to recontact the same person, so during the call, ask how you can recontact him, or her. At minimum, the person’s name, the date/time you called and some notes on what you discussed will help you in follow-up conversations.
- If you talk to multiple people, try to understand whether they’re all frontline employees, or if some are supervisors, or management. It can help you if you have some idea of the structure of their organization and what each person has the authority to do for you.
- Be respectful. Treating a call-center employee any other way will not help you and, in fact, could deprive you of an ally. It’s better to have them on your side than against you.
Insurance claims strategies
- Call the insurance company and get a clear explanation of the denial. Often denials of claims come with a terse three-word explanation and a code. Get them to explain exactly what the problem is and, if possible, a more thoroughly written documentation of the issue. At minimum, get them to tell you where in the policy you can read more about it.
- Enlist the health-care provider (doctor, or hospital, insurance billing staff) to help you, or give you suggestions on how to handle it. They have some incentive to help you because, if the insurance doesn’t pay, then they have to get the money from you.
- In some situations, insurance companies will have a ‘pay to educate policy’ that they can use at their discretion. For instance, if there was ‘an inappropriate emergency admission’ they might cover it in the first instance, but not in the future. It doesn’t hurt to ask.
Enlist consumer advocates
- Need Help Navigating Medicare? SHIP is Not Far From Home
- Need Help With Veteran Benefits?
- State Insurance Commissioner – See the link to State Insurance Departments on our State & Local Resources page
- How can a long-term care ombudsman help?
Perhaps you have some tips that others can use. Let us know in the comments.
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Informative article. I especially liked the tips that you posted regarding how to obtain information from insurance call centers. I especially like that you mentioned the importance of treating a call center employee with respect. Thanks for the tips!