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?
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.
I’m having the same problem with CIGNA but each time I’ve called I get a different “reason” or even, “it will be paid,” yet LabCorp has not been paid and I continue to get bills (2 bills, almost $400). I had called Cigna BEFORE I ever went for labs. They gave me the address of LabCorp and said it would be covered 100% by insurance! When, again, I believed it was resolved, I went for a mammogram. SAME scenario. Now I have 3 bills. I have kept records, but a lot of time has passed. I even have a recorded phone call in which the woman actually said “it will be denied but you have to resubmit …” (regarding my refuting of the bill, to Cigna.). Oops…. Are they supposed to actually TELL us that stuff? I have discovered that I have over-paid in the past because I trusted the ins co to be truthful. Grrrrrr. Not this time, but I am just learning about how some operate (Movie: Rainmaker). I have made so many calls to all parties and nothing is resolved.
I see that bankrate.com has some advice too.
Any class-action suits against Cigna that you know of? Count me in!
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?
#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
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.
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!
Reviving this old post with some GREAT advice received from readers:
1. WRITE to Cigna (and send it certified mail so you’ve got proof they got your letter) and keep a copy of the letter for your file, and drop the phrase “BAD FAITH”, i.e. tell them they are acting in bad faith and you are NOT giving up on this. I’m willing to bet it’s all cleared up in under 2 weeks. Best of luck and do let me know how it turns out.
2. from someone with 4 years of experience at an insurance company:
“I’m in class (pre-med, post-bac), so I’m writing quickly, but I wanted to share this with you:
Did you make sure you used a capitated lab provider? HDHP usually require these. If you didn’t, you might get stuck with a bigger bill. To find out your capitated providers, log into your patient portal.
Also, if your wife’s bill was higher (and she got a well-woman exam), not all insurance carriers cover HPV testing as “preventative” services. Depending on whether your employer is self-insured or fully-insured, your employer might have determined this (so there might be the opportunity to take it up with the right HR benefits person). Therefore, you might end up footing the bill in its entirely because of this.
Keep taking advantage of your right to appeal. There are multiple levels to an appeal. Sounds like your first-level appeal might have already taken place (its unfortunate because your wife or her medical doctor or representative have the right to be in attendance.) Look into the policies for further levels of appeals, and if possible, insist on being present.
Finally – for the sake of your credit or your wife’s – pay the bill, and if Cigna reverses their decision, have them reimburse you. You don’t want your bill to go to collections as it will impact your credit score.”
3. “You should try being on the doctor side of getting paid. Every day I have to call the various insurance companies about improper data entries, denied claims, mis-represented deductibles, copays, limits of care and so on. Everyone should keep every EOB (explanation of benefits/payment) for at least four months after the completion of treatment and payment. On a personal injury/work comp case keep it until problems and payments are resolved completely. Talk to your health care provider’s billing staff to make sure all is right with you bills and payments. Be prepared to share your EOB’s with the billing staff as they have received the EOB’s with everyone else’s names and payments on them. They would have to sort through all the other names to find your’s.
Doctors and hospitals typically have a dedicated person or team who do the coding to make sure it’s done properly. Sometimes, in fact quite frequently, the person entering the numbers on the other end will cross type something in and the whole thing gets rejected (which always means not paid). Make sure you’re getting billed for what was done, with the right diagnosis and so on. Please don’t ‘nit pick’ the bills because you don’t remember getting a bandaid or some small proceedure, unless there’s just no way it was done. You do have the right to ask, but please be observant while getting treated and ask questions as you go. Most providers will be happy to explain what’s going on, after all ‘doctor’ means ‘teacher’.
Make sure you have coverage for the proceedure or that you can arrange payment with the provider. We don’t like collection agencies any more than you do. Many providers will give a ‘time of service’ or cash discount.
In many states there is a time limit for the insurance company to make payment after receipt of claims. For most states this is thirty days. Most of them do honor this. Your provider may not send in billing immediately after your proceedute is finished, so be patient. For those who still mail in their claim forms, there is a delay in that as well, but typically no more than a week. Some insuranceswill send out a letter that they have the claim and are working on it (read stall method, but legal). They also use the ‘we need more information’ and ‘not enough information for adjudication’ excuse. This means that the provider has to gather up the notes, make a phone call (of five), fax or mail the notes to the appropriate person for ‘review’, then to follow up, chase them down, beat them into a corner to get paid. Oh yes, after that it will be another month til payment or denial is received.
Know your plan, coverage, limits, deductibles so there are no surprises. Insurance coverage is complex and often difficult to interpret. Frequently you’ll be talking to someone in a foreign country, trying to get answers about your coverage and payments. Remember that you can always ask to speak with someone in the good old USA . The overseas people have a script they work from and that’s all they get to say or do. You also have to wait for their computers to get to the ‘cloud’ and back, whereas stateside, it’s a lot quicker and better able to answer tougher questions. Please don’t waste their time with stuff you should be able to figure out on your own. Read the EOB, look at the code key at the bottom, it will probably tell you what happened to that bill/payment. When you call your company, the best attitude is, ‘can you halp me with?’. Shouting at them really doesn’t get you anywhere, but I do remember a doctor who did and he got so wrapped about it, he was screaming at the person on the other end and keeled over dead in his chair still hanging on the phone. They respond much better to kindness, understanding and requests for help. “
Hello, I have also had many problems with cigna. They aren’t paying for my child’s therapy services that the doctor requested she get. We now have a bill of over 4,000. I spoke with cigna again today and they were actually helpful.
We are now trying the reconsideration process, which would mean just faxing all information to support the claim for therapy services and hopefully they pay up. Also they asked to have all the dates of services with any information because obviously they don’t know?
Ugh we pay good money for Cigna and they don’t pay shit!! I’m beyond fed up with insurance companies, they only pay for you to maintain not get any better. What is wrong with these insurance companies making big buck of the consumers and not holding to the purpose.
I could’ve written this post. Same EXACT problems for every preventative care. Cigna did not pay ONE claim correct in 2013. I’m still trying to get one claim for last year paid. I filed an appeal through Cigna to cover at the rate they should (80%). They agreed to cover 80%. Never fully paid and now appear to think this is settled only covering 60%. Worst insurance company I’ve ever had to deal with.
I was diagnosed with stage four Cancer two years ago. It’s the type that will not ever get better. They are giving me a shot every 6 months that is keeping the Cancer from growing and spreading. It is basically keeping me alive. I worked for the public for 44 years, I missed only about 20 days in the whole 44 years. I missed two weeks between jobs. Now I’m on disability social security. I decided to apply for Obama care because I could not afford the Cobra insurance on social security disability. They turned me down twice because I didn’t make enough money. ??? The third time they accepted me. I had United Health Care at work, then went on Cobra with United Health Care. It was costing me $764 a month, but the insurance paid well and covered my medical needs. Then I decided to stay with United Health Care with almost the same plan. Then I went to the same doctor that had been keeping me alive for over two years to get my six month shot. I didn’t think much of it at the time about the insurance. I handed them my new card before I got the shot, nothing was said about the referral that I would need before getting the shot. To make a long story short, I am also taking Casodex, to slow the Cancer. Without insurance it would cost $500. I pay $4. The insurance turned down the shot that is keeping me alive. That shot is $4000. Because I didn’t get a referral from my doctor. Same shot I had been getting for over two years. They won’t pay. I can’t afford that with my income. Why would they pay for the Casodex without a referral but can’t get a shot without one. I smell ripoff. Nobody ever told me I had to get a referral at any time. I should have been told when enrolling in obamacare that even though the insurance was through the same company, I would need a new referral to go to the same specialist I had been seeing for two years.
My wife’s company switch to Cigna and our nightmare started. After a hospital stay for three days because of a Doctor giving me two drugs that my body didn’t like. We incurred close to 10,000 out of pocket expensive $5600 because the company said the doctor wasn’t cover and this didn’t count against our deductible or co-pay.
Fought daily with company file complaint with insurances commissioner and ended up being told that I couldn’t file any more complaints for a year. They refuse the FL state commissioner and me from doing anything.
I ended up playing to protect my credit. President Obama has screw all of us. Now people have coverage but you pay more and get a lot less. I figure between what my company pays and my wife and I pay its $1100. a month.
It s seems we left Cigna and move back to our old company but now the are doing the same thing. Prescriptions that use to be $15. co-pay are $100.00 to $35.00 United heath Care. Paying the same thing before but now $400. a month co-pay added for prescription’s.
Where does it end?
I have had numerous issues with my health insurer over the years from not reimbursing me for premium overpayments, incorrect charges for doctor visits, deductible miscalculation, max out of pocket miscalculations, IN/OUT Network applied charges errors, etc…
Each time I went through the proper channels by contacting the representatives, sending emails, and numerous phone calls.
Most of my issues were corrected this way, albeit taking way longer than it should have.
But a few times, 3, the only way I got a response/correction from my insurer was to send (old fashion CERTIFIED mail) a detailed letter (complaint form if required) to my states bureau of insurance, HHS department, (name of 3rd escapes me, but it’s listed by law in all health insurance contracts), and to my insurer with a list of people letter was mailed to.
Getting anything corrected with a health insurer is a long drawn out endeavor, I recommend.
From the very first call keep track of when you called, the number you called, who you spoke to, and what transpired.
Keep all paperwork, especially EOBs.
If you can communicate with your insurer via email DO IT, there is no he said she said. It’s there saved to all ways go back to for reference.
Follow your insurers complaint/grievance process.
Be patient, it’s very hard but you have to be patient.
Be persistent, if your told something is to be addressed in 48 hours call in 48 hours to check.
Obtain your insurers contract, sometimes called Evidence Of Coverage EOC, NOT Summay of Benefits.
Read your contract and try to take the time to understand it.
Deductibles, copayments, coinsurance, etc is very confusing at first but if you take the time to figure out how it works it’ll same you a lot of frustration and probably a lot of money. Not to mention it’s a skill that will be needed for years to come, dealing with your insurer and helping friends and family with theirs.
I, too, am fighting with my insurer. I received a id card from them with the primary care provider and other pertinent information. So I went to the doctor on the card, he ordered tests and I had them done. Well, imagine my surprise when I started receiving from Quest Diagnostics. I am on SSDI so I have no money to spare. I wrote to United Health Care, the administrator of my particular coverage. We have been going back and forth on this issue since November of 2017. United Health Care says they don’t show me being a “member”. I gave them all the information on the card received and it seems like someone from outer space sent me the card. Since my coverage is under Medicare, every time I contact them, I copy Medicare. I don’t think medical care should be so difficult. When I lived in California, I never had this type of issues. I had Medicare and Medical. Whatever Medicare didn’t pay, Medical did. The entire insurance industry is a racket, but the gold mine is in healthcare.
If you know that YOU are in the right and have all your paper work to back things up: Insurance Companies DO NOT like Consumers to know this but——-Look up the “State Insurance Commission” for your State and they will have a complaint form. They are over every Insurance Company and the Insurance company has only 48 hrs. to answer the complaint and a BIGGGGG stack of papers they have to fill out!!!! They Hate to be turned into these people!!!!!!!!!!!!!