Insurance

Your Insurance Company. Friend or foe? Many families with large volumes of medical bills often wonder just what it is their Medical Insurance Carrier really does. Do they help, or do they hinder? Sometimes it can be very hard to tell.

Every company is different. Some cover certain benefits that others may not. Premium amounts can vary widely along with co-pay policies and services available. Often families find themselves forced to make a decision between two or more insurance programs offered by employers only to discover none of the offered programs will work very well for their needs.

Often the best strategy is to choose the program which most closely meets family needs and then look for other sources of help.

(If you are looking for information about being UN-insured please go to the "Financial Issues" section of this website.)

1. Get to know your insurance company...and help them get to know you.

   For families with large medical expenses constant communication with their insurance carrier will be vital. Before talking to anyone...READ YOUR MANUAL!! If you have difficulty in understanding any of the information that may be pertinent to you be sure to contact your carrier's Customer Service office and have them answer questions you may have.

   After educating yourself, educate your insurance company. They will need to know that you have a medical difficulty in the family and you are going to be requiring a lot more from their customer service and benefits office. Calling them will do several things:

   • It will alert the insurance company that there may be a higher number of bills going through their office. Having the billing office "in your corner" can often work to your advantage by assuring quicker response and payment times for medical bills, complaints, enquiries by providers, etc.
   • Many companies will assign a personal liaison, or case manager, who will assist you in navigating the company's different departments. This may be an RN with prior medical background or a customer service representative skilled in navigating company policies and offices.
   • You will be able to find out policies regarding catastrophic limitations, co-pays, alternative programs they may offer, etc.

   It is the consumer's responsibility to find out as much information as possible regarding the particular medical insurance program they are on.

   NEVER ignore letters received from your insurance company and be sure to call them with any questions you may have. Clarify benefits BEFORE you go ahead with treatment!

2. Documentation-If it's not on paper, it didn't happen!

   Any time you call to speak with your insurance company, regardless of the department, there is certain information you will need to keep a record of. Basic details of the conversation, any messages left, if written down, can save a lot of time and hassle down the road.

   Insurance companies are generally large corporations with many individuals. They often have difficulty tracking conversations between different offices, branches, and even personnel within departments. By keeping a record of who you talk with, when you spoke, and a short synopsis of what was discussed, it becomes simpler to track your business with the company. This becomes especially important when arranging for billing reviews, permission for out-of-network use, and explanations of benefits. It is not unusual for an insurance company to accept your notes as an official record of decisions made provided your notes are accurate.

   (click here for Call Form or click here to go to the Forms Section)

   It is important to keep your notes on file along with the billings and EOB's you will receive.

   Other items that should be kept on file include EOB's, copies of letters of authorization or denial, benefit updates, and any other general correspondences between you and the company. These may come in handy later and should be kept for a minimum of 3 years with the exception of financial statements, which should be kept with your income tax returns and rotated accordingly.

3. Case Managers

   Parents who have children with major medical difficulties may find it helpful to request their insurance company assign a case manager to their case. Most of these case managers are RNs whose job is to oversee heavy utilization of benefits. These individuals can help you with authorizations, benefit information, coordinating between equipment companies, physician's offices, treatment facilities, pharmacies, and any other places that you may need to go. They can be one of your best allies. They can also be one of your worst enemies. Again, keep notes! Keep track of what you discussed, any decisions made etc. Be sure to have these notes handy when calling and be prepared to fax them in if requested. This will help alleviate any confusion. Case managers should have their own notes maintained but they may not always be accessible and/or accurate. Having your own copy will assist in making sure your case is managed properly.

   *Note: Linda recommends keeping frequently contested or reviewed bills, EOB's, conversation notes, correspondences and faxes in a single binder. This allows for immediate access to records while on the phone.

4. Financial Tracking

   Keeping track of your insurance payments and medical bills is your responsibility. It is helpful to match your explanation of benefit (EOB) statement with your actual bill. Double check amounts paid vs. amounts owed. Also double check that the amount paid is the amount agreed upon by your insurance company. If the numbers do not match, you may need to call both the provider billing office and your insurance company to ensure the proper amount has been paid. Following this practice can save you money in the long run.

   By keeping track of her EOB's, Linda found a $70K discrepancy between payments and statements.

   (See details of this story in "FINANCIAL ISSUES")

   File your documents by provider matching EOB's to the billing statement it refers to. This will help you keep track of what has and has not been paid.

5. Complaints

   Any time a consumer has a complaint regarding any of their insurance companies business it is standard procedure to begin with the company first. Give them a chance to make the situation right. Be sure to document the process while you're doing this. If case management cannot resolve a problem and billing and supervisory staff cannot assist either, you may need to request mediation. Most insurance companies have a complaint mediation policy. Check your manual. If the problem cannot be resolved through that process, a call to your state's Department of Insurance (look under the state government section of your local phone directory) will enable you to file a complaint and receive additional assistance.