Health Insurance Claims - Mini-Survey

[rantk81]

I'm just curious how often there are problems with the processing of medical insurance claims.  It happens so often to me (probably 75%+ of the time) that I think it cannot possibly be coincidence. Do insurance companies screw these up (always in their favor) as a normal course of business, relying on you to fight it every time?

What insurance company do you have, and how often do you need to follow-up with them in order to get them to process claims correctly?

Just in recent memory, here are some of the things that have happened to me.  In all cases, I contacted the insurance company, and after several back-and-forth, I was always found to be "correct" in every case and had the claims successfully reprocessed in my favor:

- Providers who are actually in-network have had the claims initially processed as if they were out of network.
- Routine/Physical stuff not coded as routine and initially not covered 100% (This has happened for a variety of reasons with a variety of excuses from the insurance company -- the most recent of which they mentioned it was due to the "order" in which the claims were processed)
- Incorrect co-insurance and/or deductible amount applied to claims

[netskyblue]

Unfortunately, I wouldn't have the foggiest idea how things are coded or are supposed to be coded, so wouldn't know if they were wrong.

I *have* called ahead to see if a particular form of birth control would be covered (this was pre-ACA), and was told it would be, only to be told at the doctor's office after having it done, that my insurance didn't cover it.  I said, "oh no, that must be a mistake, let me call them," and did, and was told over the phone "yeah I can see where they told you that, but that person was wrong, it's not covered."

I've also had an EOB not match the bill I received and spent a few months trying to get that sorted out.  The billing company told me they'd extend the due date until they figured out what happened, but I was so paranoid that they would just report me to collections anyway.  I'm perfectly happy to pay what I owe, but if the bill is incorrect, I want it corrected, you know?

[Samsam]

I have BCBS NC and they haven't screwed up a claim.  Occasionally I will visit a Dr's office or hospital that doesn't file one of the bills correctly through insurance.  I always check my EOBs before paying.  If there is no EOB I call up the office and say "yo you didn't send this to my insurance, I'm not paying it" then the office resends to the correct place.  But I don't think those are the fault of my insurance.

Before we underwent fertility treatments I made sure to get all the codes the Dr would be using in billing and made sure those were correct with my insurance and that they were covered.   Its a little more leg work than I usually do, but if things are coded incorrectly it gets expensive fast!

[Michael in ABQ]

Haven't really had any major issues. Did have an annoying one last year when my insurance company realized they had miscalculated our deductible slightly on every single bill for about a year (probably 10-15 total). It was something like $1-2 on each one but they sent out a separate letter (sometimes multiple ones) for every single one. Then I had to gather a few of them and send them a single check and a letter outlining which particular bill numbers my $11 check was supposed to cover. Honestly, there's no way it was cost effective for them to generate and send out all those letters and then process the resulting payments. They should have just eaten those few dollars as their mistake in not properly calculating deductibles and never bothered me (and probably tens of thousands of other customers).

However, since my insurance is through the military it's very cheap ($220 monthly family premium) has a very low deductible ($150 per person, $300 for the family, $1,000 max out of pocket per year) and covers almost everything, I can't complain too much.

[jlcnuke]

Never had a problem with BCBS of GA.

[slappy]

In my experience, the issue is generally with the doctors office billing incorrectly.

[Catbert]

I have Kaiser Permanente so ynever have to file a claim.

[Sibley]

Well, you're over simplifying this process. The doctor's office often bears responsibility for these types of issues.

VERY high level, here's how it works:
1. Doctor's office fills out a claim, coding procedures, adding all the patient info, etc and submits it to the insurance company(ies).
2. Insurance company processes the claim and determines what's covered, deductibles, coinsurance, etc.
3. Insurance company pays doctor and notifies the individual what they owe.

The biggest point of breakage is #1. The doctor's office. If they fill out the wrong form, fill it out wrong, forget to do it, send it to the wrong place, use the wrong procedure codes, etc - then it's wrong. And this stuff is complicated, and keeps changing. The medical world just switched over from one set of codes to a much more detailed set of codes. Probably TONS of errors happening there.

Now, the insurance company absolutely can mess it up. The more complicated something is, the more likely an error is. So, if you've got two sets of insurance, it's harder to get it right. A claim for a week long hospital stay including surgery, tests, ICU, etc is way more complicated than a simple doctor visit for an ear infection.

Rantk81, the 3 examples that you list I see broken out like this:
1. In vs out of network providers - The doctor's office may have done the claim wrong. It's also possible that the listing of in vs out of network doctors at the insurance company is messy. Without further detail, this could go either way.
2. Procedure coding - the doctor's office almost certainly messed up. The insurance company may have contributed, but it's usually the provider side.
3. Coinsurance/deductibles - This one can go either way. When you have coinsurance, that just makes it harder in general so errors are more likely.

What you should be doing to help at least catch stuff:
Actually read all the EOBs. Match it to a doctor visit. If you can't or don't understand, call and ask. Fraud is a thing, so if nothing else you'll be helping to combat fraudulent insurance claims (which raise costs for everyone in the end).

If your provider has a billing person who sucks, you either deal or find a new provider. You could complain to the provider's office that they're always screwing up claims and please figure it out, but they may not do anything.

[Sibley]

Haven't really had any major issues. Did have an annoying one last year when my insurance company realized they had miscalculated our deductible slightly on every single bill for about a year (probably 10-15 total). It was something like $1-2 on each one but they sent out a separate letter (sometimes multiple ones) for every single one. Then I had to gather a few of them and send them a single check and a letter outlining which particular bill numbers my $11 check was supposed to cover. Honestly, there's no way it was cost effective for them to generate and send out all those letters and then process the resulting payments. They should have just eaten those few dollars as their mistake in not properly calculating deductibles and never bothered me (and probably tens of thousands of other customers).

However, since my insurance is through the military it's very cheap ($220 monthly family premium) has a very low deductible ($150 per person, $300 for the family, $1,000 max out of pocket per year) and covers almost everything, I can't complain too much.

FYI, they probably were required to send all those things separately. Yes it's annoying, but blame your state government.

[I'm a red panda]

I have Anthem BCBS.  I had hundreds of claims in the past few years.  LOTS. And expensive stuff.

I would say we have a weird screw up on rare occasion.  I had some issues with my hospital stay after my daughter's birth because the hospital didn't actually code c-section anywhere and therfore I should have stayed fewer nights then I did. (They did code for an operating room though... insurance can't connect the dots though.)  It took about 20 minutes of calls to get it straightened out; the hospital sent new coding eventually (though they insisted they were not wrong.)

Recently my EOB showed a denied claim for my gallbladder surgery; but I was never billed for it, as it was hospital error and it was fixed in the back end.

I had an issue that cost me thousands of dollars because a procedure was out of network, and they should have covered it in network, because there was no out of network provider available and it was a medically necessary procedure. But they wouldn't, and I lost the appeal, and I chose not to take it to the state board of appeals because it was an emotionally exhausting process and not worth the money to me.  So because it was out of network, it wasn't subject to my out of pocket max, nor adjusted for allowable charges by the provider. So I paid $13,000 to the provider, and received a reimbursement of about $2,000. I should have been reimbursed about $10,000. 

[Sibley]

I have Kaiser Permanente so ynever have to file a claim.

There's still a claim, you're just not seeing it. Kaiser's model helps simplify a lot and makes it a lot more seamless to you, but behind the scenes there's a similar process. But since they control a lot more end to end, they can do a lot to make sure claims don't get screwed up at the front end.

[EricEng]

I had Aetna for most of last year with lots of claims.  Most were fine with a few needing corrections.  As Sibley said, they were all the fault of the hospital filing the claims wrong.  The insurance company was a champ commonly running the issues to ground for us when we notified them of something amiss.

[rosarugosa]

I have United Healthcare.  We have a lot of claims activity unfortunately, but have never had any issues with claims processing/payments.

[mm1970]

Every large claim.

Childbirth
Major surgery

Every one of them has been wrong, and has taken months to years to get settled.

Doesn't matter the company, ours have changed a lot, sometimes annually.

[Dollar Slice]

I had BCBS in MA for a long time and I think one time I had a problem which was solved with one phone call.

I had Aetna in NYC for 3 years and it was a disaster. Constant problems, and their website was a clusterfuck so I had a terrible time finding in-network providers when I needed them (and they couldn't help me over the phone, either). Like I was trying to come up with an orthopedic surgeon with a particular specialty and the search would come up with cardiologists and oncologists. The first ortho I went to was on their website but it turned out he was in-network but not in the PREFERRED network so I had to pay $700 because I didn't understand their website. It also took me 8 months and many phone calls and letters to convince them that a drug store walk-in clinic is not a regular physician's office and you do not need a referral to go there because it is classified under urgent care. They also rejected blood tests that I had taken in my PCP's office, because apparently I'm supposed to ask which lab they're sending my blood to and make sure my insurance company is OK with it before allowing them to do it, just in case they changed to an out-of-network lab since the last time I was there.

Have had United HC for a year now - a busy year with a ton of appointments (surgery & PT) and only had one problem which was solved with 5-10 minutes on the phone. And I got charged $25 for something that I'm not sure I should have had to pay for but I didn't really care at that point (they literally asked for my credit card to charge $25 in the hospital less than an hour after I got out of surgery... what the fuck? but that's on the hospital and not the insurance).

The clear differences between Aetna and the other two has convinced me that either Aetna is incredibly incompetent or is purposely mishandling claims in the hopes of padding their profits at your expense.

[Catbert]

I have Kaiser Permanente so ynever have to file a claim.

There's still a claim, you're just not seeing it. Kaiser's model helps simplify a lot and makes it a lot more seamless to you, but behind the scenes there's a similar process. But since they control a lot more end to end, they can do a lot to make sure claims don't get screwed up at the front end.

Yes, I guess., but in my geo area the doctors are employees of Kaiser and Kaiser owns the hospital, the lab, etc.  Kaiser owns the entire process.  I've never had a bill in 40 years much less had to deal with after the fact denials.  My husband and a neighbor had cancer at the same time.  All we paid was the expected $40 co-pays for oncologist visits.  Our neighbors got stacks of bills daily (new bills, old bills, overdue bills,  revised bills etc).  After confirming that his oncologist was "in network" he found out the hard way that the lab the oncologist used wasn't.   

[hops]

Anthem BCBS. Last year I received around 70 EOB; there was only one problematic claim and that was a screw-up on the hospital's end. Nor were there any snafus with my prescription coverage (my medications cost a small fortune). There were a few coverage approval delays about particular tests or medications, but those didn't involve me; the doctor's office took care of everything and then Anthem sent me confirmation in writing.

[TheWifeHalf]

The majority of the problems we've had has been due to coding being wrong - easily corrected with a phone call.. One time I was paying for brain surgery, ironic because 25 years later I had a traumatic brain injury.

When my daughter was little I went to sit on the couch between 2 kids to read to them, and sat on her arm. We had to go to the ER where the doc said it was dislocated but it popped back in on the way to the ER because the xray showed it as normal.
I got the bill that included $900 for the dr putting it back- easily corrected.

We've had various issues over the years and most were coding errors. So, I check EACH bill

[BeardedLady]

As a private practice doc, I can tell you this happens all the time. The reps at insurance companies are under-trained (or purposely mistrained? Some days it seems that way). A few times I have even had a claim accepted, received payment, and then the insurance company demands a refund 6-12 months later saying the service was not covered. It really sucks to have to call the patient to request payment a year later when they thought it was handled.

[Sibley]

I have Kaiser Permanente so ynever have to file a claim.

There's still a claim, you're just not seeing it. Kaiser's model helps simplify a lot and makes it a lot more seamless to you, but behind the scenes there's a similar process. But since they control a lot more end to end, they can do a lot to make sure claims don't get screwed up at the front end.

Yes, I guess., but in my geo area the doctors are employees of Kaiser and Kaiser owns the hospital, the lab, etc.  Kaiser owns the entire process.  I've never had a bill in 40 years much less had to deal with after the fact denials.  My husband and a neighbor had cancer at the same time.  All we paid was the expected $40 co-pays for oncologist visits.  Our neighbors got stacks of bills daily (new bills, old bills, overdue bills,  revised bills etc).  After confirming that his oncologist was "in network" he found out the hard way that the lab the oncologist used wasn't.

Yep, you're exactly right. Kaiser is a combo provider-insurer. There are pros and cons to it. When it works well, it's GREAT. When it doesn't work, it's a massive pain.

FYI - the actual payments were more to do with details of your policy than how Kaiser works, and you probably had much higher insurance premiums than your neighbor.

[spicykissa]

Have not had any issues, but we are generally healthy and only have a 2-3 claims per year.

The one frustrating time was a trip to the ER for a possible broken wrist. The radiologist remotely reading the x-ray was 'out of network' (which was pretty funny), and there was a bill from his group, a bill from the hospital, and a separate bill for the PA who wrapped it and told me it wasn't broken. We have a HDHP, so these were submitted to insurance but paid out of pocket.

Over a year later, I got a small refund check out of the blue, as it's apparently not allowed to sneakily charge out of network fees like that--it's not like I had a choice who read my xray at an in-network hospital.

[SimpleCycle]

So there are a few issues here:

1. I work with physician billing data as my job, and I can tell you that most problems with insurance claims originate with billing problems on the provider side, not the insurance company side.

2. Some insurance companies have very poor customer service staff, which turns a simple "the provider needs to resubmit" into a huge hassle for the patient trying to track down what actually went wrong.

I have had a lot of problems, but they all originated at the same two physican offices.  Basically their billing departments are crap, billed wrong, tried to blame it on me, and got an "OH HELL NO" in response.  In all the cases I wasn't on the hook for anything and in one case got a refund.

[BTDretire]

My son was victim of a hit and run bicycle rider. he had multiple injuries,
but the only mis-coded (I suspect deliberately) item were sutures in his scalp,
the cut was just an inch long, but was coded as a 3' laceration.
 I didn't contest it, but it was an education checking medical codes and comparing.
 My son is fine, He was knocked unconscious for a short time, he had another laceration on his leg
and multiple scratches plus sore muscles for a while.