First Person: Challenging Your Insurance Coverage on a Medical Bill

Yahoo Contributor Network

When my husband went in for a physical two months ago, he plunked down $20 for the co-pay knowing that our health insurance would cover the rest. It came as a shock then when we received a $300 bill in the mail with the explanation that our coverage was denied.

We were certain that what had happened was a simple medical billing error made either by the doctor's office or the insurance company. Here's how I challenged the insurance coverage on our bill and ended up not having to pay anymore than the original copay amount of $20.

Refresh the memory. The first call I made was to my husband at work, asking if he could remember the purpose of his medical visit and what procedures (such as lab and x-ray) were done. Once I had that information, the next step was to gather up our insurance card, the denial of benefits statement, and our medical bill so they would be at my fingertips when I made my calls.

Insurance company. Since it was our insurance company that denied the claim, I started with our claims adjuster first. I learned that while our policy did provide a wellness benefit of one physical a year, we had already made another wellness claim that year which is why coverage was denied. I went back through my EOBs (explanation of benefits) from the past year to determine that his last physical had been in the summer of 2011.

Doctor's office. The last call I made was to the insurance and billing department at the clinic. In speaking with the billing clerk, I related what the claims adjuster had said and provided the clinic with the date of my husband's last physical from a year ago. It took 10 minutes of backtracking for the clerk to discover that the visit had been coded incorrectly which triggered the denial. She called the insurance company while I was standing by "on hold" and successfully resubmitted the claim using the correct set of numbers.

When it comes to billing errors, mistakes happen more often than we think. So much in fact, that medical experts estimate that between 40-80% of all medical bills contain some kind of error. With those kind of statistics, double checking our medical bills for mistakes and challenging uncovered expenses is a habit everyone should develop.

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