The only people who enjoy dealing with health insurance claims are, well no one.  It is usually an emotionally-charged, frustrating, and often confusing discussion to have with someone over the phone.  Health insurance companies have the goal of paying out as little as they can.  You, as the recipient of health insurance, pay good money on the premium and expect to have the most possible amount of money paid out on your claim.

So we arrive at quite the conundrum.  Two opposing forces, fighting for opposite goals.  Most of the time, you have a lot more to lose than the insurance employee on the other end of the phone.  That is why you need to make it a priority to get everything that is owed to you.  Here are some tips to battle your insurance company over a claim.

Tip 1 – Make Responsiveness Your Best Weapon

One of the biggest areas of frustration when it comes to getting a claim paid, is the seemingly endless amount of time it takes.  Unfortunately, there are deadlines which should act as your encouragement to resist apathy.

Communication between you and the insurers can take time.  Then they also have to review the material.  Therefore it is your job to push the process along as fast as you possibly can.  If you are in the process of getting a claim paid, pick up the phone where ever you are.  You never know how long it will take to get back in touch with your insurance company.

Make sure you note who you have talked to, what you talked about, and what the next step in the process is.  Having these answers ready will ensure that nothing is falling through the cracks on your end.  Staying organized is a huge benefit to you.  Scan all of your medical records and denial letters as PDFs so that you have copies handy.

Doctor Visit by Laura Smith, on Flickr.  This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 2.0 Generic License.

Tip 2 – Check the Medical Codes

Your doctor’s office, hospital, and health insurance company all use a set of codes to identify procedures, tests, and ultimately, how much you owe.  These codes could be the key to unlock why your claim may have been denied.  For example a procedure code (CPT) used by your physician may not match the diagnosis code (ICD-9) can result in a denial.  Simple errors like these can be corrected and alleviate a lot of headaches.  These mistakes may become increasingly more common due to the current switch to ICD-10, the new set of diagnosis codes.  Hopefully, your physician’s office will employ the use of a professional coding service, otherwise the internal staff will have to handle the transition to the new set of codes.

Tip 3 – Double Check the Math

Everyone receives an “Explanation of Benefits” which tells you how much you have to pay.  This changes based on things such as in-network charges versus out-of-network charges.  Make it a priority to know your premium, deductible, coinsurance, and copayment.  Understanding these costs will help you understand the bills you receive from your insurance company.

When you understand your charges you can double-check the math on the bill because mistakes do happen.  If the bill does not match up with the explanation of benefits you may need to call your insurance company or health professional’s office.

Tip 4 – Appeal

If your health insurance claim is ever denied, appeal.  A huge percentage of denials are overturned on appeal, which means that you have a decent shot at having your denial overturned.

Your appeal should include your identifying information along with objective information to your case.  Use information such as your insurer’s medical necessity policy and relevant medical records.  Research how to write appeals and then work on yours.  Have it proofed afterwards and then send it by certified mail so that you know when it is received.

Tip 5 – Build Relationships with the Right People

This may seem odd; a tip that advises you to build a rapport with an insurance agent.  However, it can be extremely beneficial down the road.  If you have any minor communication with your insurance company and find that someone on the phone has been especially helpful, ask for their name and direct line.

Next you should try to build a relationship with any health care professionals you see.  This can include any specialists and especially your primary physician.  Make sure you fax along any updates you receive from specialists to your primary doctor.

You should even build relationship with vendors such as lab technicians, pharmacists, and home medical equipment providers.  Knowing which health professionals can get insurers to cover these vendor services will help if and when something does eventually happen.