BACK IN 2000
, Ginny Akers had a magnetic-resonance-imaging scan performed on her knee. About a year later, Akers, 59 years old, received a phone call from a collection agency. She was told that she had 30 days to pay a $900 bill since her insurance company had refused to pay the claim. "This was the first I heard about it," Akers says.
When Akers called her health plan, Capital Administrators, she was told that the claim was indeed denied because she had gone to an MRI center that wasn't part of its network. Akers quickly pointed out that the facility was listed on the plan administrator's Web site as part of the network. The company still refused to pay the bill, and the collection agency was breathing down her neck. After three months, many phone calls and the help of CareCounsel, a patient-advocacy firm employers hire to help their employees deal with insurance problems, the claim was finally paid. "I just didn't know what my rights were," she says. The company makes it a priority to fix claim errors, says David Reynolds, president and chief executive officer of Capital Administrators.
Akers's experience is hardly rare. Some 91,000 thousand formal complaints against health plans are filed with the Department of Labor each year. And experts believe that represents just a small proportion of the disputes patients have with their health insurers. According to a recent study by the Kaiser Family Foundation, nearly half of all consumers report some kind of problem with their health plans. The most common complaints include delays or denials of coverage or care, billing and payment problems and difficulty seeing a physician. And now that nearly 80% of consumers with private insurance have some type of preferred-provider plan or other form of coverage that allows them to see out-of-network doctors, the potential for disputes over claims will only grow. While in-network doctors are paid negotiated rates directly by health plans, insurers can question and reject charges by outside providers.
And if you've ever opened an "explanation of benefits" from your health plan and been amazed to see how a $400 claim can be nickeled, dimed and reasonable-and-customaried down to a reimbursement of $14.95, you know what can happen. But that doesn't mean you have to roll over and accept whatever your health plan tells you. In fact, patient protection is improving, says Salvatore Castiglione, chief of the consumer-services bureau of the New York State Insurance Department. For example, many states, including New York, have expanded consumer protections allowing patients to appeal denied insurance claims to an independent panel of physicians.
In dealing with your insurer, just learning what your rights are is half the battle. And sometimes simply knowing how to get more information out of your health plan will help you discover a simple and costly clerical error. Here are some strategies that can help.
Start With Your Plan
When you have a problem with a claim, your first step should be to call the customer-service number listed on your explanation of benefits. Experts recommend that you have all of your paperwork in front of you during the call and that you keep meticulous records listing all phone calls and correspondence with the insurer.
The customer-service representative should be able to tell you why a claim was denied or not paid in full. If it's a simple administrative error (which tends to happen quite often) the rep can send the claim back through the system with, for example, corrected coding and ask that it be reconsidered. Thanks to multiple administrative errors, Samantha Lau, a 29-year-old in New York City, had to ask her insurance company, Aetna US Healthcare, to resubmit her claim for an annual check up with her gynecologist four times over a span of five months before the insurer finally paid the bill. "After a while [the delays in payment] just seemed deliberate," Lau says. "If an Aetna member believes that a claim has been denied inappropriately we encourage them to contact Aetna," says a spokeswoman for Aetna. "Over the past year we've instituted two programs specifically focused on providing world class customer service to our members, customers and providers by handling claims and customer service phone calls accurately the first time, every time."
If phone calls to the customer-service number are unavailing, patients have the right to request a formal review by the insurer. This request should be made in writing and sent via certified mail, says Larry Gelb, CEO of CareCounsel. "You want to make sure you have a record that the company has received the letter," he says. This will also help insure that your request is dealt with in a timely manner. Be sure to make your request promptly. Many plans have time limits for complaints. Aetna US Healthcare, for example, will grant reviews only within 60 days of receipt of the original explanation of benefits.
A formal review entitles you to see all the documentation that was used to determine your benefits. You could uncover an error, such as a wrong code used for a certain procedure, that could change a denial to full payment, says Lauren Casalveri, vice president of consumer service for Cigna Health Care. That's what happened with Ginny Akers's MRI. Only after CareCounsel requested a formal review and was able to look through the documents was it discovered that the MRI center submitted its claim using the name of one of its radiologists rather than its own corporate name, prompting the rejection.
What about contesting those often-miserly usual, reasonable and customary rates? "We have a fee schedule and that is firm," Casalveri says. Even so, if you shopped around and your eye doctor's fee is in the same ballpark as three other ophthalmologists', you should question the insurer. Firm fee schedule or not, Casalveri admits that Cigna will investigate discrepancies and sometimes make changes. "It's not common, but it does happen," she says.
Still getting no results from your health plan? It's time to call in the regulators to act as your advocate. Contact your state department of insurance (or in some states the department of managed health care) and file a complaint. Many states let you do so online.
Even a pro like CareCounsel's Gelb sometimes has to take matters to a higher authority. He recently filed a complaint with the California Department of Managed Health Care after his son's visit to the emergency room for stitches went unpaid for six months. First he tried working with his insurer, but after his health plan missed a collection agency's deadline for payment, he knew he needed to apply some additional pressure. The claim was paid immediately after the insurer learned of his complaint. "This is just a striking example of how the system breaks down against the consumer," Gelb says.
In more complex cases, claims are sometimes denied because the insurer deems a treatment not medically necessary, experimental or investigative. If that happens, most states now allow patients to request a review by an outside panel of physicians. If the panel overturns the insurer's decision, the company must pay for treatment. When a 15-year-old boy's request for surgical correction of his webbed toes was denied because his health plan deemed the surgery not medically necessary, the California Department of Managed Health Care stepped in. An independent panel of doctors examined the boy's medical records and decided that the surgery should be considered reconstructive, not cosmetic. The insurer's decision was overturned.
In fact, in the 41 states (plus the District of Columbia) that offer consumers the option of an external appeal, the insurers are overruled in about half of cases, with the rate of patient victory ranging from a high of 72% in Connecticut to a low of 21% in Arizona and Minnesota, according to a report from the Kaiser Family Foundation.
If you work for a large employer, odds are you're covered by what's called a self-funded plan. In these plans, your employer is actually paying your claims and simply uses an outside health insurer as the administrator. Unfortunately, your rights are somewhat more limited in a self-funded plan, since they're not subject to state regulation. So instead of seeking help at the state level, you'll need to knock on the federal government's door. File your complaint through the Department of Labor's Pension and Welfare Benefits Administration. (You can reach the PWBA at 866-275-7922.) A benefits adviser will take your call, make sure your plan is being administered fairly and in some cases can overturn a denial if the health plan's decision was made unfairly. This may happen if the Department of Labor finds decisions aren't made uniformly for all of a plan's members.
Self-insured plans are likely to remain exempt from state external-review programs as long as the proposed Patients' Bill of Rights languishes in Congress. The legislation would extend the external review process to all health plans, but it's unclear whether the bill will ever get passed.
You can still opt to sue your employer, but that might not be a career-enhancing move. Instead, you're probably better off contacting a state patient advocate. Most states, or in some cases a municipality, offer some form of consumer health assistance program that's either funded by the state or is run by a private, nonprofit organization working under contract. Your local department of insurance or state attorney general's office should be able to help you locate an advocate in your area. While these officials have no legal power over your health plan, they understand the system and can ask the plan administrator the right questions on your behalf, says Kevin Simpson, executive director for the Health Assistance Partnership, a project of the nonprofit group Families USA. Sometimes just having an advocate can help, he says.
To try to head off any problems before they start, make sure you read your plan's rules very carefully. And find out what your plan will cover before you go to your next doctor's appointment. But don't let the system intimidate you. A healthy dose of rebellion may force your insurer to cough up the dough it owes you.