How do i fight with an insurance company and win?

Question

I had surgery in June and my insurance has no deductible. The insurance company paid the doctor and the pathologist, but they wont pay the hospital. the insurance company says they havent gotten a bill. the hospital says they have sent it and received a denial with no explanation from the insurance company. I dont know what to do. I've asked for the hospital to send me the bill to submit myself, but they dont do it. They say they do, but I never get it. I'm so frustrated. What can I do??? The hospital has an out-of-state company do their billing or I would go there in person. My insurance company is also out of state. *sigh* help.. i have no deductible, there is no reason why they wouldnt pay, they've paid everything else I just think the hospital is messing up. any suggestions?? thanks!

Answer 1

At this point I don't think it's the insurance you need to fight. It's the Hospital. I mean if you haven't gotten what they promised to send you numerous times, you think the insurance got their claim? If the insurance denied it, it would state a reason and if not the Hospital would have called to find out the reason.

Call the hospital billing department and tell them to fax you a copy of the insurance EOB (explanation of benefits). If the insurance denied your claim there will be a claim number given by the insurance company. If they don't do it then tell them you want to talk to a manager. Once you get the denial you can call your insurance company and give them the claim number. They can look it up this way to pull up the denied or paid claim. Also Ask them to fax you your UB-92 form for your services there. Call them while your standing next to a fax and explain to them that they were suppose to do this serval times and you have not received it so you'd like to stay on the phone with them until the fax comes through. Again if they do not help tell them you want to talk to a supervisor.

Everytime you insurance processes a claim they should be sending you an explanation of benefits too showing you what they paid for each of your services. Look for these and match them with your statements.

Also, many insurance companies have online services where you can pull up your claims online. So YOU can pull up everything they ever paid for you and if they denied a hospital claim it will say so on there.

Finally, if you insurance did deny the cliam they give you a certain number of days to appeal the decision. You may want to pull out your policy manual and see what that is for your plan. An appeal is a written notice to your insurance carrier stating you do not agree with their decision.

A lot of the times your physicians office will be willing to help you. Call they billing department at your physicians office and explain to them what's going on. They may know someone at the hospital who can help.

Good luck.

Answer 2

Riiight... This sounds like a really disorganized hospital billing office. If your insurance company received a bill, and denied it, you and the hospital would have received an EOB in writing, from your insurer. Since this document doesn't seem to exist, I'd say the hospital has either 1, not sent a bill to your insurance. or 2.Sent a bill, with inaccurate information. (ie, the insurance company couldn't identify you with the information listed on the claim.) I think a lawyer in this instance is overkill, and would be a waste of your money.

I think the previous suggestion of using your insurance company's website is a good idea....

Or, call the hospital... again... and speak with a manager... Or, call your insurer, and beg them to help.... Depends on your carrier, but most will have someone available to help... OR, if your insurance is through your job, some companies offer a point of contact for specific insurance issues. See if one exists for you.

What does the statement look like the hospital is sending you? If it has a brief description of the services, and charge amounts, the insurance company may be able to process a claim with that info... (Depends on the type of contract they have with the hospital) Not all that likely, but possible.

Maybe try a written complaint to the insurance company and the hospital, sent certified mail to both... anything in the mail sounds like taking the long way.

Good luck!

Answer 3

The Hospital says it received a denial; this means there should be a claim number. Call the billing agency and have them read the claim number to you over the phone. Then, call your insurer (the number should be on your card), give the service rep. the claim number, and ask him or her to look the claim up. If there is no such claim in their system, the Hospital is deceiving you. On the other hand, if there's a claim, your insurer can explain to you why it was denied.

One important question you MUST ask your insurer: "Am I financially responsible to the Hospital?" If the Hospital is a participating provider and it failed to follow its contract with your insurer, you are not financially responsible.

Another suggestion: when you call the billing company, demand to speak with a manager. Don't take no for an answer. Explain what's happened and demand to be faxed the information (the denial they say they received AND the UB 92 claim form they say they filed) so you can help get this claim paid.

Finally, if these things don't work, send a written complaint to the insurance commissioner in your state and request assistance. All commissioner's offices have highly skilled investigators who will get to the bottom of what's going on -- AND who will make sure you're treated fairly.

Answer 4

You can go to the insurance board... They should have sent a notice of cancellation via certified mail. From the day the cancellation was processed, you then have 10 days until your insurance will actually go out of effect (I process cancellations and reinstatements for an insurance company)... well, this is the way it is in CA anyway... If your mom sent in an October payment, someone should have called and brought it to her attention. Also, if they went ahead and charged her because they didn't receive a payment, then she is COVERED for September! You might want to let us know what state you are in since there are different laws... Might get better help that way. I'm a rookie, so if anyone has any corrections to what I wrote, please advise...

Answer 5

At this point, you've done everything you can. As long as you document EVERYTHING, there's not a lot the hospital can do to you. Here's what I would do next:(just to doubly cover your butt!) send the hospital a certified letter in writing to the billing person there (or whomever you've spoken to there asking for copies of the bill) requiring whomever gets the letter to sign for it. In the letter ask them to fax you the denial and the bill as proof within 5 business days of receiving the letter. Tell them if they refuse to comply with your request, legal action will be taken. (Keep a copy of the letter and the certified receipt.) I would then consult a lawyer if they don't respond - since your beef isn't really with your insurance - it's the hospital.

At this stage, since you've contacted the insurance and the hospital, it's the hospital's burden of proof to prove to you that they've been denied payment.

Answer 6

Ask them to send you a certified letter with the copy of the bill and denial from the insurance company. Also document every communication with them and your insurance company. You are probably going to want to get a lawyer if it is not settled soon, so you will not end up in collections.

GOOD LUCK!!!

Answer 7

It's most likely the hospital...especially if they have an out of state billing company doing their billing. They screw up all the time.

You are entitled to a copy of the billing; you should request it in writing and should send it certified mail. Also, get the phone # of the billing company, the hospital should give that to you.

Answer 8

You do not fight with an insurance company and win. Your lawyer fights with the insurance company and wins. Sometimes wins big time. I'm sensing there is not a lot of money involved here, but if a lawyer can make a case for bad faith insurance practices, a jury could award millions of dollars in punitive damages. Insurance companies know this and get a little nervous when a claimant gets lawyered up. It might be worth paying a bad faith litigation lawyer for a half hour of his or her time. They may tell you to forget it, or they will take your case on a contingency basis.

Answer 9

Have the hospital fax you a copy of the denied claim. It should only take them a few seconds and I would stay on the phone with them until it is received. Once you have that in your hands it will be easier to talk to the insurance company.

Answer 10

I would suggest from my own similar experience, that you contact the office of the attorney general of your state. they'll assign a mediator to investigate your case. They helped me get $2600 back that my insurance company denied to pay and I paid to avoid collection. But at the end I got reimbursed the $2600 by the efforts of the attorney general office. They are useful in cases of health care billing problems. Best of all, you pay nothing. You already pay taxes. I hope this helps