Navigating Claims, EOBs and Insurance Companies

by Kathryn Whitaker, mom to Will, John Paul, Anna-Laura, Clare and preemie Luke

Photo credit: Whitaker Family

  1. Create a notebook. A big one! Some suggested dividers include: Bills – (discharge summaries, doctor instructions) and Government / ECI. The visual learner in me used that system to keep the mountain of paperwork straight. Having that data at your fingertips makes conversations with medical providers and others go much more efficiently.
  2. Keep a log. Every time you talk to a doctor’s office, government office or insurance company, write it down. Jot the name of the person you spoke to, the date and time and the outcome or requested action. This comes in incredibly handy the next time you call and they have difficulty remember or pulling up the topic you discussed. They need to know you are keeping them accountable and it helps you keep things straight!
  3. Ask for a supervisor or manager. If you have a complex problem, never talk to the first person that answers the phone. Instead, ask for a supervisor right off the bat. This will save you hours sitting on hold.
  4. Request an e-statement. Ask for an e-statement (every insurance company has a related version), which outlines every claim, what was paid, what amount was applied to your deductible and to your in-network out-of-pocket expenses for every provider. It’s best to ask for this information after the new year for the previous calendar year, but you might also consider asking for a report in July for the previous six months as a double check.
  5. Negotiate. Providers are notorious for saying things like, “We only have a three-, six- or nine-month payment plan” and then making you choose. Here’s the deal. You don’t have to pay on their schedule, you pay on yours. Don’t let them convince you there’s a service charge associated with paying on your schedule either. After you set the payment plan, you can always call back a few days alter and see what discounts are offered if you settle the bill in full, sometimes up to 40 percent!
  6. Reprocess your claim. If your insurance company turns down a claim, stating that it’s “not under your coverage plan”, call them back and request that it be reprocessed. On three different occasions, my insurance company processed three claims as out-of-network (OON), when they should’ve been in-network (IN). Here’s the skinny. Even if it was an OON provider, but they performed the service IN, you’re covered under your in-network benefits. Anesthesiologists and pathologists are your usual culprits.
  7. Request an itemized hospital bill. If you have a hospital stay, ask the hospital to send you an itemized bill. You will be amazed (and horribly shocked) at what you’re on the hot seat for come bill paying time. If you notice something that didn’t happen, or that you were charged multiple times, call and contest the bill.
  8. Follow up. If a provider says they will reprocess the claim and resubmit it to your insurance company, ask for the timeframe and then tell them you plan on calling and confirming they did it. Things happen faster when they know you’re watching. Do the same for your insurance company.
  9. Develop a relationship with one insurance agent familiar with your case. I’ve found it’s useful to ask for the same customer service representative every time I call. She gave me her ID# and I use it if they won’t transfer me. “Rachel” is very familiar with our family and it helps to talk to the same person just about every time.
  10. Ask questions. If something just doesn’t look right, call and ask. I did that on an OB claim that came through. When I talked to the insurance company, they said it wouldn’t be covered, but lo and behold, the claim got paid shortly after I called. It never hurts to ask.
  11. BONUS! If you receive a bill and they say you’ll soon be sent to a collection agency, don’t believe them. I mean, yes, if you don’t pay your bills for years, I suppose that would happen. BUT, a few months of waiting while insurance kicks in, they reprocess some claims, etc., and you’ll see many of the problems work themselves out.