Help! My Health Insurer won’t Pay the Bill!
My Health Insurer is Not Paying the Bill
I am willing to bet that many of you have encountered a situation where you noticed an error in your medical bill, but your health insurer delays in fixing it and paying the remainder of the bill.
I am encountering my first such scenario. I’ve learned some important lessons, but the situation is still not resolved. So I thought I’d share what I’ve learned and then turn over the advice giving to those of you who have been down this road.
I’ll follow up with the end results in a later post.
Long story short:
1. This year, I switched from a traditional PPO, to a high deductible health plan (HDHP) through Cigna, in order to save money on our health insurance.
2. My wife and I both wanted to take advantage of a $200 HDHP bonus incentive for showing up for an annual physical, which is a preventative service and 100% covered by the HDHP. We did so, the appointment was paid for, no problem, and we later received $400 in bonuses in our health savings account (HSA).
3. At the appointment, the doctor scheduled routine preventative blood work for both of us. There was no suspicion of illness.
4. We get our blood work done, and later get bills for the full amount. Mine was $153 and my wife’s was $459, much to our shock!
5. After a few months, numerous interactions in which the Cigna told us we need to call our doctor because they did not use “preventative” CPT codes (doctor says they did, and really have no incentive to make that up). However, I am able to get them to pay all but $16 of mine and $120 of my wife’s.
6. $136 is better than $612, but I’m pretty damn determined. If everything is truly “preventative”, I shouldn’t have to pay anything at all. I don’t care that the payment would come from funds contributed by my employer to my HSA! It’s about principle. By this time, one of the bill’s has a threat of upcoming collections on it – which gets me even more fired up. I call Cigna back, and this time, did what I should have done in the first place – received a confirmation # on the case and the rep’s name. He tells me they will re-submit the claim.
7. I awaited their verdict on the re-submission.
8. Once again, Cigna comes back with the “non-preventative CPT codes” argument.
Lessons learned thus far:
- document everything
- get a case confirmation # right away
- get the name/number/extension/email of the rep. you call, to help instill a bit of accountability on their end to resolve things
- triple check every medical bill you receive to make sure it is correct
Medical Bill Apathy
This whole situation has been very frustrating and makes me wonder how many people simply give up on medical bills or don’t realize there is an error in the first place. My determination has already prevented a loss of $476, however, I won’t stop until they pay the full $612.
If they stall again, however, I’m out of ideas on how to make that happen.
Your Advice on Getting the Health Insurer to Pay the Medical Bill
- Have you been in a similar situation where the insurer seems to be lagging on paying the bills? How did you get things resolved?
- Have you tried bringing in a third party to help you resolve the billing dispute? Did it work?
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I am G.E. Miller, & 
Ugh. Health insurance companies are my nemesis. I had a baby last year, and my insurance company (United Healthcare) did the best they could to get me to pay for multiple services that were in fact covered. I probably would have lost out on close to $2,000 were it not for my diligence in reviewing every bill and calling and resubmitting claims, yada yada. Once they denied a claim for acupuncture by saying that my company had changed our plan and no longer covered that service. I checked with HR and nope, they hadn’t changed the plan. I had our HR person get involved in that dispute, and was (finally) fully reimbursed. That’s my advice, I guess, is see if your employer HR person can weigh in with the account manager. The account manager seems to be more motivated to keep customers happy.
Whoa. This is a sore topic for me as well. One year I recall switching from Kaiser HMO to HealthNet PPO because I was single and basically didn’t have to pay extra premiums for ‘better’ health coverage.
Kaiser has nice hospitals while doctors w/ HealthNet had dingy offices in run-down buildings. I remember being ‘referred’ to specialist places from my doctor and still getting billed from those specialists. I got burned once for less than $200.
Tried to get reimbursed to no avail. Crooks probably got paid twice. The following year I switched back.
I can completely relate…
A few years ago, I got billed over $300 for healthcare related to my eyes. Having expected this to be covered, I immediately contacted my health insurance company, and just like you, they said they would re-submit it, but then it was denied again. After multiple rounds of this, I called the doctors office and spoke with the person that handles their billing. Luckily, this woman was great, and she went above and beyond what I would have expected. First we did a 3-way conference call with me, the billing person at the doctors office, and the insurance company. We got the insurance company rep to verbally state the bill would be covered by the insurance company, but they still denied the reimbursement by paper. After that, the billing person submitted a lengthy personal letter explaining my condidition and why it should have been covered, signed by my doctor. After that, I never heard another thing. Either the insurance company paid up, or the doctor’s office ate the bill. Hopefully not the latter, because in my opinion, that office earned every cent of the bill.
My reaction to reading this was a sort of relief that you finally got bitten in your quest to save money. I’ve been following this website and looking with a bit of envy at all the ways to save money – by switching phone service providers or whatever – and as someone with job three kids and tight schedules and no time for these two hour long phone conversations with people who are just trying to stall you into giving up – I opted to stick with Verizon,stick with Comcast, stick with United Health Care, stick with Aetna dental, etc. I know that I’m probably paying considerably more, but I guessed that I would get burned and get bogged down into some dispute, which I know I would take personally, even though it’s not worth my time.
I guess what I’m saying is – and this is a frustration for me – in order to save money you have to prepare for this sort of a situation from time to time. If you can handle the stress of it, go for it – in the end you win. I lose sleep over these things.
Well, I’m glad my readers are relieved by me getting dumped on….. I guess…?
I don’t think it’s a matter of getting burned as a result of the pursuit to save money. Paying more does not equal better customer service – you’ve been a Verizon and Comcast customer – you should know that by now!
I wouldn’t let fear of lower service levels get in the way of saving money. In my opinion, benefit of the money saved has far exceeded any negatives. Even if I get stuck with the bill in this case, I should come out $1k+ ahead vs. sticking with the PPO.
To be honest – my experience with Verizon is not very good at all, in particular their internet/FIOS division, which is a headache. I’m surprised the Verizon always gets the top ranking.
But somehow, they make the tops in most of the customer service rankings. When I was considering switching to Virgin Mobile, I read through review after review which said there were all sorts of issues with them and similarly priced phone services.
Verizon does not give me 100% quality all the time, but I feel like, after reading rankings and reviews, that if there were any major issues these could be cleaned up much nicer by Verizon than with Virgin Mobile. It’s hard to quantify the difference. If I were a single grad student I would easily go with the less expensive option.
Great article, unfortunately this is a common problem and I hear about it quite often.
There is something different about healthcare that creates an universal problem among the many different participants in the system, the most striking being that the consumer has no say in what services are rendered, what services are covered and how much he or she will ultimately be responsible for paying. It is not an uncommon scenario that a doctor requests a service, the patient follows the doctor’s orders, insurance either pays only a portion or none at all and the patient is left holding a bill.
Another common scenario is a patient who calls his or her doctor to ask for the price of a particular service, only to be told the price is unknown. No one would go into the local electronics store and request to buy a TV without being told the price, yet in healthcare, this is often the case. However, the health insurance companies, traditionally known as a sort of gatekeeper to healthcare, have recognized this and in recent years have tried to improve price transparency. Despite these efforts, there are many pitfalls associated with health insurance coverage and learning how to navigate around these should make for a more educated healthcare consumer.
I review claims for Clients and look at Medical Bills each day – on an average I find 80% have mistakes!
Here is our Current Health System:
1. Prices are not Posted?
2. Each Medical Provider has Negotiated a different rate?
3. Prices vary from Provider to Provider?
4. Non-Contracted Physicians can charge anything?
Factoids:
#1 According to a report published in The American Journal of Medicine, medical bills cause more than 60 percent of the personal bankruptcies in the United States.
#2 According to that same study, approximately three-fourths of those that do go bankrupt because of medical bills actually do have health insurance.
#3 If you have an illness that requires intensive care for an extended period of time, it is really easy to rack up medical bills that total over 1 million dollars.
#4 It is estimated that hospitals overcharge Americans by about 10 billion dollars every single year.
#5 One trained medical billing advocate says that over 90 percent of the medical bills that she has audited contain “gross overcharges”.
#6 It is not uncommon for insurance companies to get hospitals to knock their bills down by up to 95 percent, but if you are uninsured or you don’t know how the system works then you are out of luck.
#7 One study found that approximately 41 percent of working age Americans either have medical bill problems or are currently paying off medical debt.
#8 Health insurance premiums for small employers in the United States increased 180% between 1999 and 2009.
#9 Even as the rest of the country struggled with a deep recession, U.S. health insurance companies increased their profits by 56 percent during 2009 alone.
I will stop here; but if you want to hear more feel free to contact me directly by email or phone.
Rudy Lehder Rivas, Owner
http://www.HSAInside.com
Health Insurance advocate and Broker for 20+yrs
This is a very common issue i see as health broker. It also points out why you should work with and have a good broker you know and trust. We can talk to you about these things before the claim is incurred.
Fore preventive care, once a diagnosis is given, the claim switches to diagnostic instead of preventive and will immediatley cost you money. The most common one is a colonoscopy screening which should be covered 100 percent. If they check you out and find anything, you now will have a 2000 bill on your hands.
In defense of the insurance carrier, they react directly to the claim cpt code they recieve….If it is coded prevemtive then they pay100percent, if not it gets covered a different way. The issue in this particular case is getting the doctor to resubmit the claim with the appropriate code. Cigna will then reconsider. If all else fails, appeal, appeal, appeal!
Hi! This was a great article.I recently had some orthodontic work done,and when I was about to leave the orthodontist they told me my remainder balance.They also said that I have to pay it for that month,at least since they haven’t heard from my insurance company.I ended up paying a portion of it,since the woman there say I will be reinbursed for it.She also said that they are providing more coverage,so I will probably get even more of a reinbursement back.I paid what I could and left some unpaid.Then I called my insurance provider.They said that they were sorry,and that there was an error in their system,and that they’d pay it.Later,I got a letter in the mail telling me what they’ve paid.So I called my old orthodontist to see when I’d get my reinburstment,and they said that they will call me back when payment has been made because no payment had been made.I then called muy insurance provider AGAIN,and the lady on the phone says that the system(or whatever) won’t approve the claim.She told me she did not even know why.SO,now I’m just waiting for them to call me back and pay the bill.I guess they felt like since its only xxx amount of dollars that they can stop paying.Or maybe they thought both me and my old orthodontist wouldn’t notice that they didn’t pay.I don’t know,but insurance companies make me sick.At least with Orthodontist they cna tel you before hand how much you have to pay,unlike with dentist.Who pretty much refuse to tell you how much things are going to cost until after the work is already done.
Hi Miller-
They say something like a few hundred billion dollars are lost every year in the medical industry due to errors, incomplete filing etc. A third party (such as a insurance bad faith lawyer) can help you- BUT usually these lawyers work on a contingency fee basis. They receive a fixed portion of whatever settlement you receive so for a very small amount, they may not be willing to take the case or charge you something so exorbitant it wouldn’t be worth it.
However in extreme insurance bad faith cases, where the insurance company is being egregiously negligent either with delays or partially witholding payment then they owe you PER day they lag. Speak to a lawyer in your area- theres a lot of rules and paperwork as to how these cases go. Theyll be able to tell you what the rules are concerning your state/situation
Recently my husband had to take me to the E.R. , due to the flu virus. It was a Sunday night 10 pm, so no Dr office was available of course! I couldn’t breath, chest was tightening and the room was spinning! The E.R. dr on duty, immediately ordered chest xrays, an EKG, blood work…etc. Those were just 3 out of maybe 5 tests he chose to run on me. He came to the conclusion that I had upper respiratory infection, along with sinus infection! My airways were becoming blocked! He gave me prescriptions for an inhaler, Tylenol with codeine,and a ZPAC. Well, then to our surprise, the insurance company stated that the E.R. was not necessary for the event, so they will not pay! The Dr coded it as non emergency. Health advocate that we notified, said the same. We were suppose to call the ins company and get their permission to go in their opinion! Then find out there is no one to answer that call on a Sunday night! We have a PPO. No referral needed on our policy for a specialist. Why do I need someone that sits behind a desk, with no medical degree, to tell me by phone, if I need the E.R. or not? We pay a lot of money every week for medical insurance and hardly use it!