Here are some tips on how to get an insurance claim expedited by your health insurance provider. I deal with UHC. Your mileage may vary:
1)Be sure all of your paperwork is in order. Before you start fighting, be sure the company has all the proper forms on file. There’s nothing you can do if the right forms haven’t reached them.
2)Send a formal letter asking them to review the claim. A formal request for review gets logged in their system. The one from your medical provider does too, but it’s not as potent as the one you send. Also, mention things like being prepared to file a formal complaint with the Attorney General. And mean it. If you aren’t prepared to do this, you aren’t ready to do what I just did below.
3)Prepare to spend 4-6 hours of time on the phone over several days. Once I get really good at this, I’d like to get it down to 1 day, but for now, prepare for about 2-3 days of haggling.
4)Keep a record of dates/names/times you contacted people. What company you called. What they said. Ideally, you’d never get disconnected or have to call back, but inevitably, you will be telling your story to several people several times. Cut down on the number of people you have to start the process over with again by hanging on the line and just being transferred as long as possible. Tell them you won’t get off the phone until the issue is resolved.
5)When you reach Customer Service, ask to speak to a supervisor. Whatever you do, don’t get stuck with a first-pickup person. You want to get to the third tier. Immediately state that you have an expedited claim. The second are the second tier folks may have different names: Rapid Resolution Specialists, Resolution Specialists, Resolution Managers, Customer Care Managers, Customer Care Specialists…Once you have a reference number (ask for this once you reach a resolution manager) you can just immediately ask the support person to transfer you. Customer Service is the first line of defense, and all they can do is read to you what you see on your own screen when you log into your insurance account online. Nobody can do anything to physically change your account until you get to at least a 3rd tier person. That means getting to the supervisor/resolution specialist’s supervisor, at the very list.
6)Have a list of ways that you will escalate the call. “If they say this, I will respond with this.” Sometimes you have to hang up and call back several times before you can frame your argument correctly. This is understandable, since we’re often pretty emotional when battling for health services.
7)DON’T EVER LOSE YOUR TEMPER OR GET EMOTIONAL. Don’t EVER lose it with a customer service rep. Be firm, but not hysterical. I lost it twice along the line, and got stonewalled both times. The first time, I had to call back and start all over again with a different rep. The second time, I apologized, explained the situation, and got the payment processed in 30 minutes. Stay calm, but firm. Firm is good. Have your situation story written down so you can recite it calmly. You’ll be repeating it a lot.
Here’s an example of how to keep a record of your contact with the various folks involved in resolving a major health insurance issue (and yes, I know, it would be wickedly funny if it wasn’t true).
December 17th, 2008
So, Jason at CCS Medical, provider of my Omnipod insulin pods, contacts me and says they are withholding my Omnipod shipments until UHC pays outstanding claims from 7/1 and 10/1. UHC claims that the provider is Out of Network. This is untrue, as they have already signed paperwork with CCS Medical to get the in-network rate. They already have the pre-authorization form on file. They’ve had the paperwork for 6 months. Prior to that, it took a year of bullying from Omnipod just to get approved.
Now that it’s approved, UHC isn’t paying.
Jason says they submitted a formal review of these claims to UHC on 12/4 and have still not been paid. He advises me to put pressure on UHC. Mmmm pressure.
December 17th, 2008
I call UHC. The claims rep says it takes 30 days to review claims. I should wait another two weeks for the Dec. 4th claim to be processed.
I submit a written request for review of claims to UHC. This includes EOB documentation and threats about filing a complaint with the Attorney General (not just threats, actually. This same day, I request a list of the other outstanding complaints against UHC in order to prepare my own. I prepared early for the long haul).
December 22nd, 2008
UHC receives my request for review. CCS Medical calls and is told it will be another 2 weeks to correct these claims (I learn this on the 5th).
December 24th, 2008
I check the status of my claims. My online UHC records show that the 7/1 claim is in the process of being adjusted. Somehow. It involved a duplication of the claim, only with a “– “next to it, which I could not understand but figured must mean something was happening to the claim. There was no other explanation. Just the duplicate claim with minus marks next to it.
January 5th, 2009
I ask to speak to a supervisor. I’m told there is no supervisor. I just need to be patient.
I call CCS medical and tell them that the claim is being processed. The Rep from CCS medical gives me a breakdown of their previous contact with UHC (see above). She offers tips on how to bully my way past the customer service rep.
I call UHC back and use bullying techniques (buzz words like “rush,” “expedite” and “this is not acceptable” and “today.” Because resolution of this claim will result in failure to deliver much-needed medical supplies, I explain this loudly and often. The fact that it’s true, and the idea of going back to shots terrifies me, helps me with my argument. I do, in fact, need this expedited. Today. Now.). I am transferred to a Rapid Resolution Specialist. Specialist assures me that claim is being processed and will certainly be processed this week. If it’s not processed by Wednesday, I should call back then and hold a conference call with UHC and CCS Medical to get things sorted out.
At this point, I am exhausted, and out of fight. Fighting for a shipment reminds me of how much better I’ve felt since going on the pump, and how much shittier my life will be without it. That’s the thing with switching to a pump. If you’ve never had it, you don’t know what you’re missing. Once you’ve had it, you realize how much better your life can be. When someone tries to take that away, it’s terrifying.
I hang up.
January 6th, 2009
8:00 am –After a long night spent detailing my escalation procedures (including a list of “if they say this, I say this,” prompts to help me when I get overly emotional about it) I call UHC and ask about the status of my claim. They say it is still pending. I tell them I need to put a rush on it.
I ask to be transferred to Rapid Resolution Specialist. She fights it, but eventually transfers me after I tell her it needs to be resolved TODAY so that my medical supplies will ship TOMORROW. Again, the fact that I urgently needed medical supplies NOW was a good selling point, cause let me tell you, I wouldn’t be going through this for a bandaid.
The Rapid Resolution Specialist is surprisingly perplexed and helpful about my claim. She says they can put a rush on it, but it will still be 24-48 hours to process. She warns me, however, that I have a pre-authorization that expired on Dec. 31st. I ask if that will delay payments already not made. She says no. I tell her I’ll advise CCS Medical of this (having no idea who the hell handles pre-authorization forms).
She transfers me to her supervisor, since she has no way to directly change anything on the screen. Supervisor says she and another manager will get it to someone who can actually change the screen and it will be reviewed and out the door today.
RRS supervisor tells me someone WILL contact me either tonight or early tomorrow.
This whole process took about two hours, about an hour and a half of it, total, on hold with UHC. Most of it while the supervisors tried to figure out who the hell they could get to expedite the claim.
7:00 p.m. – Martika from UHC calls and says she spoke to Deanna at CCS. Martika told them my 7/1 and 10/1 claims had been incorrectly processes and would be paid. Martika says that Deanna has released my shipment.
Hooray! I am full of win!!
January 7th, 2009
8:30 a.m. - I call CCS Medical to verify that my shipment has gone out. I’m told it’s still on hold and will not go out today. I’m told there are no notes on the file from Deanna or Martika.
I find this annoying, but not, ultimately, surprising. This is, after all, why I called to verify.
8:45 a.m. - I call Omnipod to see if the holdup is on their end. Perhaps UHC called them instead of CCS?
I get transferred to Billing. Billing sends me to shipping.
I get transferred to Shipping. They tell me to contact CCS medical.
9:30 a.m. - I call CCS Medical back. I speak to L. I tell her to check the notes. I tell them Deanna should have released this from hold. I’m told Deanna didn’t have the authority to do that.
I’m told that it’s because my “pre-authorization form” has expired (as of 12/31/08). It was resubmitted to UHC by CCS Medical yesterday, after they received confirmation that they would receive payment. They could not submit a new pre-authorization form without getting payment first (??).
I tell them this shouldn’t be an issue. I was told all I needed to do to receive today’s shipment was to get them to pay the prior claims.
She says she will call back with more information.
10:45 a.m. - I call CCS Medical. I am told my shipment will ship today and is not on hold!
Hooray! I am full of win!!
11:00 a.m. - I get a call from L. She says I have been misinformed. My shipment will not ship today until the pre-authorization form is processed by UHC. She says they tried to get a rush on it but were denied. She suggests I try and get a rush on it.
12:30 p.m. - I call UHC.
I get Gail in Claims. I tell her August/October/Rush/Expedite/Medical Supplies.
I’m transferred to Coletta the Rapid Resolution Manager. I tell her August/October/Rush/Expedite/Medical Supplies.
I ask to speak to her supervisor, Debbie. I tell her August/October/Rush/Expedite/Medical Supplies.
Debbie tries to stonewall me with, “It’s still processing, process, process, time to process…” This is what every claim rep says first off. What you tell them is that these are urgent medical supplies and they need to go out TODAY. Must be resolved TODAY. Has been processing for SIX WEEKS. ALL FORMS ON FILE.
I lose it with Debbie. I’m afraid this slip up has ruined my chances of getting a resolution. I apologize and explain I’ve spent about six hours on the phone over the last three days with half a dozen people at three different companies.
She says she will contact her manager and call me back. She says she will get it paid today. I told her that’s great – should have happened yesterday. Now I need her to expedite the pre-authorization form. She says they already have a pre-authorization on file for 1/6 to 10/31 2009. She will work on this and get the payment made today.
1:15 p.m. - I call L at CCS Medical and say pre-auth is already on file. She says this isn’t true – UHC was just saying they have a record of it, but it hasn’t been processed. I tell L. that they will call me back today when the claim is paid, and I will get auth # then. L. advises me to conference call in CCS medical with UHC – calls are recorded, and shipment can go out immediately after end of call.
2:10 p.m. - Debbie calls back from UHC. She says the initial 7/1/08 claim has now been paid (record! It’s only been six months!). When I ask about the pre-auth and conference call, she says her department doesn’t handle that: “What we have on file is a… placeholder,” she says. “It’s still being processed.” I ask her to expedite (RUSH, RUSH, EXPEDITE. These are the KEY WORDS). She says to call the department that handles that and gives me the number.
2:15 p.m. - I call the Customer Care Management number (or whatever the hell touchy-feely name they gave this place). I tell her August/October/Rush/Expedite/Medical Supplies. I am told this is the wrong department and given a new phone number and transferred.
2:35 pm. - I speak with Chris? I tell him August/October/Rush/Expedite/Medical Supplies. He finds the actual name of the actual person (with a first and last name!) assigned to work on the actual pre-authorization and transfers me to him (My God!! I’m going down the rabbit hole!!).
2:36 p.m. - I get voicemail for Adam. I say August/October/Rush/Expedite/Medical Supplies call me back immediately here’s my number.
2:45 p.m. – I start to document the whole sordid history of this claim.
3:00 p.m. - Adam calls back!
I am achingly polite to Adam as I tell him the August/October/Rush/Expedite/Medical Supplies story. This is the fifth time I’ve explained it today.
He says this is no longer his case. He transferred it. He gets the name of the manager in charge of the person in charge of the pre-auth (Sandra – he also gave me her last initial. Deeper into the hive I go!). He puts a rush on it (his term is “stat”) and says they will call me back today on the status of the pre-auth.
4:08 p.m. – Jenn from CCS Medical calls and says that UHC has called them and approved the pre-authorization form . The shipment will go out today. She has already personally released it. She asks if I would like it to go 3-day air instead of 5-7 days ground. I say yes, since I only have 6 days of pods (that would be – 2) left.
I will receive my shipment Monday morning.
I hang up.
There is no moral to this story. Oh, what’s the line, what’s the line…
One of the women turned to me just before they left. "We all battle dragons," she said. "There's no shame in losing."
"There'd be no battle," I said coldly, "without the dragons."
She grinned, slid her hat back on. "There will always be dragons," she said. "It's only a matter of who plays the dragon, who plays the sheep. Which would you rather be?"