Don't Get Ripped Off by Mistakes on Health Insurance Claims

Dealing with medical bills and insurance claims can often become a full-time job. Too often, the insurance company makes errors on claims and bills, which can be costly to seniors and their caregivers. The first step to make sure this doesn't happen to you is to become familiar with all of the details of your coverage, says Sheri Samotin, President of Lifebridge Solutions.

For example, if your insurance has both in-network and out-of-network benefits, make sure you understand the difference. When you make an appointment with a new provider, ask if they are in your network and then check this out yourself on your insurance plan's website or by calling their customer service number.

Likewise, many plans require a referral and/or pre-certification from your primary care doctor for certain visits to specialists or for specific procedures. Don't assume that your doctor's office has checked this out for you. If they say that they will take care of it for you, call your insurance plan yourself anyway and find out if the provider did indeed call and whether the service will be covered and at what level. Understand the difference between what your provider charges and UCR (usual, customary, and reasonable). Most plans pay benefits based on a percentage of the lower of the charge or UCR and not based on a percentage of the actual charge. Finally, understand your deductibles and co-insurance responsibility.

Even when you do everything suggested above, there will be times when you don't agree with a provider's bill or how your insurance plan has processed the claim. Here are seven tips to help you handle mistakes on health insurance bills and claims.

7 Tips for Disputing Health Insurance Billing Errors:

  1. Keep detailed written records of every contact you have with the provider or insurance company – dates, times, who you spoke with, what they said, next steps, etc. If you fax something, keep a copy. If you email something, keep a copy. If you mail something, you guessed it, keep a copy.
  2. If the customer service person makes you a promise, get it in writing. So if the hospital says they will adjust or write-off a charge, ask for written confirmation, preferably by email. If the claims adjuster says that they will investigate your issue, ask for them to write you a note indicating this, along with a projected timeframe for their response.
  3. If your account has wrongly been sent to collections, demand that the provider immediately correct this and provide you with a written explanation that you can send to the credit reporting agencies.
  4. Request detailed bills from your provider, and review them carefully. If you don't understand a charge, ask for an explanation. If the explanation doesn't make sense to you, ask to speak to a supervisor. If you believe that a charge is inappropriate (either an error or outright fraud) don't hesitate to challenge it, preferably in writing. If you believe fraud is involved, report it to your state's insurance department and/or federal agencies (in the case of Medicare, for example).
  5. If something doesn't make sense to you on a bill or explanation of benefits, question it right away. There are usually grievance or appeal procedures, but these must be done within the timeframes stated in your policy documents.
  6. If you are told not to pay a bill while it is being researched or revised, get it in writing! If you agree to a payment plan or a partial payment as "payment in full", get it in writing!
  7. If you don't have the time to handle your medical bills and related insurance yourself, there are professionals available to assist you. Medical billing advocates are there to take care of these issues for you. You can choose to have a medical billing advocate review all of your medical bills, or only engage one to assist with sorting out a difficult issue.

Sheri Samotin brings more than 30 years of business and management experience to LifeBridge Solutions. She is a Certified National Guardian, Certified Daily Money Manager & Certified Professional Coach. She is the author of Facing the Finish: A Road Map for Aging Parents and Adult Children.

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