No Really, Check Again

I appreciate having health insurance, I really do. But the complexity of health insurance sometimes confuses me.

I had an in-office surgery done in June to remove a severe atypical mole from my back, along with much of the skin around it. As you can expect, that wasn’t a cheap procedure.

Since we had recently switched health insurance carriers, I expected there would be a few hiccups in the claims process. The first came with a letter from the insurance carrier letting me know they had contacted my doctor’s office for more information. No big deal, I thought.

Then another letter came asking me for more information. I provided what I could and mailed it all in. Then about a month later, I received a letter from insurance stating that none of it was covered for pre-existing conditions because they didn’t receive any information from me. A day later, the bill for the total procedure came from the doctor.

I didn’t flip out, because I’ve seen this before. It likely was a mix-up somewhere and a phone call would resolve everything. I called the insurance company in mid-September, and gave them all of the claim information. The woman I spoke with was very nice and explained that they needed proof of insurance prior to this coverage in order to process the claim and not deny it for pre-existing conditions. I thought I had mailed all of that in, but they had no record of having it on file.

She gave me the fax number for their claims department, and later that day I faxed over the proof of insurance from our prior insurance. I then called my doctor’s office and explained the situation to them, again authorizing them to provide any information needed to my insurance. I considered the issue resolved at that point. It was a hassle, but I understand mix-ups can happen. At least it was done.

Last month, I received another letter from the insurance that notified me they were contacting the doctor’s office again for more information. I had no idea what else they could possibly need, but shrugged my shoulders and figured they’d call if they needed anything else from me.

Then last week I received another set of letters telling me the claim had been denied. So this morning I called the insurance company again, and spoke with another very nice woman who wanted to help make this right. I explained it all to her in detail, and she checked the records for me.

“Oh, I see the problem. Did you have health insurance immediately before this for at least a year prior to coverage with us?”

“Yes,” I responded.

“OK, so we just need proof of your prior insurance…”

I cut her off and explained I had mailed it in once, and faxed it in again. I provided the date that I faxed it in, the number that was provided to me to send it to, and offered to send her the fax confirmation sheet showing it had been received.

“Let me check again,” she responded. A few seconds later, she said, “Oh wait, here it is! Yes, we do have it on file, right where it should be.”

“Great! So…what’s the holdup then?” If they had it, what more could they possibly need?

“We had it on file, but it looks like they didn’t realize we had it, so they continued to deny the claim. I’ll put a note on these claims to have them processed again with the information on file, and it should be completed in 5-10 business days.”

I was so confused by that statement that I could only thank her for her help and didn’t ask any further questions.

I can only shake my head at the thought that they had the information they needed to process the claim but denied it again based on missing the information that was right in front of them. At least I was able to get confirmation that it was received, and I’m grateful for friendly and helpful customer service. Having someone friendly and helpful to talk to makes the entire experience bearable.

Now let’s hope it gets processed this time so we can pay our part of it and be done. The scar will forever remind me of that visit – I don’t need unprocessed claims to further remind me as well!