As soon as I got pregnant I started mentally preparing myself for some insurance headaches. Between all of my medical appointments and health care providers, I knew some clerical errors would be inevitable. But I never expected my OB's bill to get rejected entirely. (Yes, I foolishly went with an out-of-network provider.)
Still, I didn't panic when I got the letter from my insurer that it had no plans to pay my doctor. After all, I've been writing about health insurance for more than a decade and I feel pretty comfortable navigating a claims department. Naively, I figured I could get the matter cleared up with just one phone call. Boy was I wrong. To my complete surprise, I found that it took multiple conversations before a customer service representative would even tell me or my OB why my claim was denied in the first place.
As frustrated as I am, I know I'm not alone. According to a US News & World Report article, "How Crafty Health Insurers Are Denying Care", insurance companies carefully analyze each claim with software programs that the industry calls "denial engines". And although the total number of claims that get denied nationwide is very difficult to pin down, a recent lawsuit filed by the California Nurses Association/National Nurses Organizing Committee can give you an idea of how pervasive the problem may be on a national level. This group says that California's seven leading insurers denied an average of 26% of its claims during the last six months of 2009.
Wondering what you should do if your claim gets denied? First, don't assume that your doctor has access to more information than you do. In my case, I was the one who had to tell my doctor why the claim was rejected.
Second, don't presume that your health care provider will go after your insurer until the claim gets paid. Your doc's office manager is very busy and may give up on getting money from your insurance company if the claim gets rejected more than once. Should that happen, you'll be responsible for paying the bill.
Finally, be prepared to file an appeal (or two) so that your claim is reconsidered for payment. If you have no idea what I'm talking about, do yourself a favor and read The Kaiser Family Foundation's Consumer Guide for Handling Disputes with Your Health Insurer. This document is one of the best handbooks I've come across and is a must read for anyone with health coverage.
If you're dealing with a particularly difficult and expensive situation, you may want to consider hiring an advocate. The folks at the Patient Advocate Foundation may be able to help you.
As for my claim, I'll keep you posted on how much of the bill gets covered. Sadly, I'm beginning to think that going out-of-network is synonymous with paying out-of-pocket.
UPDATE: My health insurance company finally called to say that I should receive a check in about two weeks.
Baby image by Gabi_Menashe, CC 2.0.