When dealing with health care disputes, readers have this advice: Do your homework. Be patient. And, above all, be persistent. In response to an MSNBC.com story outlining nine things that insurers don't want you to know, readers wrote to tell how they've won battles big and small over their health insurance issues.
Study the details of your own insurance policy, advises Sharon of Taylors, S.C. After you've gained that knowledge, persistence is key. "The only language that insurance companies understand is pit bull tenacity," writes Sharon. "If you have a valid claim and are extremely persistent, you will eventually wear them down to the point where it's cheaper for them to do the right thing and pay for your treatment than to continue to fight with you."
For Susan of Sysosset, N.Y., diligent record-keeping helped her win a battle against her insurance.
"I always get copies of all my medical records," writes Susan. "When recently filing an appeal, I ... found that the information I supplied regarding old test results, was the decisive factor in a positive determination for me."
Keep reading for more responses.
I have fought the insurance company and won. My wife had undergone a mastectomy after being diagnosed with breast cancer. My then-employer's insurance covered everything wonderfully. While she was healing and preparing for reconstructive surgery, I changed jobs. When she was ready for the reconstruction, I checked with my new insurance company to be sure that it would be covered. They said no and referred to the policy. When I read the policy, it stated that the company would pay for reconstruction surgery only if the mastectomy had been performed while insured with them. I protested to the company. They denied me. I submitted a complaint to the insurance commissioner pointing out that according to the policy we would have had to be prescient in order to know that we should have waited to have her mastectomy until I became insured by my current company. He agreed and now all policies issued in our state cover reconstruction without this language. Bob
I was shocked to get a bill for double the copay for some nine visits to a therapist. I made several phone calls and kept a record of who I spoke to each time. Then I made a written appeal and had to take it to the second level after the first appeal was denied. Eventually, the appeal board agreed that I should only pay the original copay on those nine visits that occurred before the rate hike supposedly took effect. My perseverance saved me over a hundred dollars!
Jump through the insurance company "hoops." Play by their rules with documentation, employee names and authorization numbers.Gregory, South Tahoe, Calif.
Know what counts toward your deductible, and keep your own running total of qualified charges, along with supporting EOBs and receipts. That way, you will know exactly when you've met your deductible. My insurance company kept an inaccurate total, and I called them on it. I sent all my records and totals to them, and although it took them months to acknowledge the problem, I received a refund of over $1,000 in charges I had paid that were covered after my deductible was already met.
After getting knee surgery to repair a torn ACL, bills started coming in from the hospital, surgeon, anesthesiologist, physical therapist, and anyone else who might have been involved in my surgery. Although every statement showed that insurance had been billed, few statements showed that the right amount had been paid. It appeared as though my out-of-pocket expenses were going to be much more than I expected! So I set up a weekly appointment on my calendar to deal with getting all the bills paid accurately. At my set time, I sat down at my desk with pencil in hand and my phone headset on my ear. I took detailed notes about people I talked with, information I learned, and the expected next steps for each bill. I found that incorrect payments can be caused by incorrect billing codes and procedures, incorrect interpretation of insurance coverage, or incorrect recording of services performed. It took about 5 months of consistent calls and diligent note taking (not to mention a few collection notices!) before every bill was paid by the correct party in the correct amount. In the end, I realized I had saved thousands of dollars by getting familiar with my policy and by not assuming that the bills were right and I was wrong.
— Lisa, Portland, Ore.
Save your receipts! ... Find the right claim form from your secondary insurance company, you may have to call and ask for a fax, email, or snail mailed copy of this form. It is so worth it! Complete the form, which is usually very simple. Then attach those receipts you saved, showing the co-pay that your primary insurer requires you to pay. Attach the receipts to the claim form (always keep a copy of the receipts and the claim form) and mail the claim to the claims department of your secondary insurance company. You will/can recover between 80% to 100% of that co-pay, meaning that your prescription medication may just cost you $0, zero, zip out of pocket. Set up a schedule — send this secondary claim once per month. You'll be glad you did.
When my wife had a knee replacement they also found that she needed an expensive drug to bring up her white blood cell count. Just before I checked her out of the hospital, I decided to go to the hospital pharmacy to get the prescriptions the hospital and our doctors had given us. To my amazement BC/BS told the pharmacist that there was a seven-day pre-approval period needed for the drug. (If you are in the hospital for surgery how are you supposed to know that you need a 7 day approval for a drug they were giving you, and how would you know that you also needed to be on it after you left the hospital?) Needless to say, I was very upset. Our hospital doctors and the hospital ombudsman called BC/BS and had a heart to heart and they finally approved the needed prescriptions. In case that did not work, I was prepared to ask the hospital to keep my wife for a few days until she did not need the drug. Long story but I would advise not checking out of a hospital until your prescriptions are filled correctly so that you have people willing to help you fight the insurance company. If I had checked out 1) the local pharmacy would not have even carried the drug and 2) I would have no way to fight the insurance company on my own.
— Edward, Burlington, Vt.
I recently found out that my Ambien (sleeping aid) came in a generic form. It will save me over 900 percent. Of course the doctor did not offer nor did the pharmacy tell me this until I complained about how expensive my medication was.
— Anonymous, Phoenix
I was a breast cancer patient in 2006. I had to fight for 9 months to get my insurer to pay for my wig. I kept providing them with the information they needed, but it seems their representatives are incapable of coordinating that information. I ended up contacting a healthcare advocacy group my employer makes available to me. These are internal staff who help people like me in a similar situation. One phone call from them and my insurer agreed I should be paid. I learned that if you have all the right codes (either diagnosis and/or other medical codes), the claim will be paid more quickly. I'm a very persistent individual. You have to keep hammering at them till a claim is paid to your satisfaction, not theirs.
— Anonymous, N.J.
I have found that I can save a significant amount of money on prescriptions by using the mail order service provided through the insurance company. They will send you a three-month supply for one or sometimes two co-payments instead of three. Be sure to have your doctor write the script for 90 days though otherwise you won't see any benefit.
— Anonymous, Cincinnati
I have found some success in getting denied claims approved. For me, the key is to keep calling and calling and calling to figure out why the claim is not processed correctly. Also, I make sure when I am speaking with them that I have the bill, the denial letter, and my plan's benefits right in front of me. ... Every time I use this method, action is taken. Although, it can take several attempts to get the correct action taken!
— Brittany, Tulsa, Okla.
Having been an appeal nurse reviewer for a large company gave me the opportunity to know the loop holes in this industry. Always have a complete benefit plan booklet in your possession. A summary of plan benefits does not tell the insured the whole story. A booklet may be up to 40+ pages. It outlines what is covered, not covered (exclusions) and also should give the the insured the names, addresses and turn-around times to file an appeal. I've had to battle several times and won for payment because I knew where to look. Pharmacy benefits are another item the insured needs to learn about. My husband and I saved almost $20,000 for a cancer treatment that was covered under our benefit for a modest cost of a co-pay. ... So lesson learned — know ALL of your benefits, medical and pharmacy. Know who your insurance company contracts with (providers, hospitals etc.) and never be afraid to appeal a denial. Most people don't bother, they think the insurance explanation of benefits is final and they are losing out on a very important right not to be heard as well as money they've already put into the system.
— Ellen, Charlotte, N.C.
Persistence, persistence and more persistence when talking with the insurance company, as well as keeping good written records of who I talked with, when and what transpired in the conversation. Keep copies of everything, as it can come back and haunt you.
— Rita, Cibolo, Texas