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gorillapaws's avatar

What's the best recourse for dealing with health insurance that is consistently screwing up the billing?

Asked by gorillapaws (28237points) January 22nd, 2022

My wife and I have a pretty decent health insurance policy with a large insurer. My wife has monthly telehealth appointments with her provider. Every month the insurer screws up the billing. Every month my wife gets furious and has to deal with long hold times, and trying to correct the error through customer service. This isn’t a large dollar amount, but it’s every month and so adds up.

She has tried to escalate the issue multiple times. Everyone agrees that it’s wrong and will get fixed in x days, or will call back in x days, blah, blah, blah. It never happens, time is wasted. Eventually it gets corrected and resolved, and then they screw it all up again the following month with the next charge.

She’s at her wit’s end. How would you proceed with trying to resolve this issue permanently so future appointments don’t create the same problem? I don’t think the dollar amount is enough to justify a lawsuit. She is certainly stressed, frustrated and has wasted many hours on hold and having conversations that go nowhere. Our state has an Ombudsman’s office for insurance complaints and I think that might be our next step, but I’d be curious if any of you have dealt with something similar? If you’ve found solutions and/or if you have some suggestions for the best next steps?

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16 Answers

Forever_Free's avatar

Are you certain it is the Insurance company and not how the medical provider is filing?
The billing is something different than the EOB from the Insurer.
It is unclear what the issue is that you are stating here. Are they denying benefits? Not met Deductible? Not met Out of Pocket?
The Insurance companies do have complexities but once you understand your policy it is clear of where the responsibility is. There are also policies that everyone has to play by. More info if possible might help.

chyna's avatar

I was just going to say what @Forever_Free said.
I had an issue where one of my doctors kept billing as “out of area” and it wasn’t something I could tell just by looking. I thought it was the insurance company, but they were paying with the information they had.
I finally figured it out and had the doctors office re-bill. The next time I went, they did the same thing! It’s ridiculous but we have to be proponents for ourselves. Think of it as checking your shopping bill to make sure they aren’t over charging you.
If, as you say, this keeps happening time after time, if it’s the same issue, maybe it’s the billing office you need to talk to.

gorillapaws's avatar

There have been many appeals (for separate, identical problems) thus far, and eventually the insurer has acknowledged it was their error in every case. Intially we suspected the fault may have been with the provider’s billing office, but as we progressed down the rabbit hole, we have confirmed that the provider is billing correctly and our insurer is making errors.

SnipSnip's avatar

Call your state insurance commissioner, and start communicating with the insurer as well as the doctor’s office in written form.

JLeslie's avatar

If you are sure it is the insurance company and not the doctor’s office and not a company that issues the invoices to you for the payment, then my question is, is your insurance through her place of work or your place of work? Or, do you buy insurance directly from an insurance company like through the ACA?

snowberry's avatar

They sound incompetent. That crap is one reason why health insurance is so expensive. I’d contact your state commissioner of insurance, along with the details of how many times they’ve screwed up. It won’t hurt, I hope it would help, and that’s what they are there for.

Zaku's avatar

The best luck I’ve had in similar situations, is persistently calling and asking different people until I find someone competent and interested in getting things right, and getting their contact info, and then only going to them for help in future. Sometimes with health insurance, you can find someone at your provider’s office who will take on the task of setting the insurance company straight, though of course that only works with bills with that provider.

Another approach that can work, is going to a lawyer, and/or communicating to them that you’re not responsible to pay inaccurate bills.

RedDeerGuy1's avatar

I would find another provider. If there is none then it is a perfect opportunity to start another competing company.

That’s how capitalism works now doesn’t it?

Tropical_Willie's avatar

Written email / letter to insurance commission; number times the same error has occurred, copy to insurance company.
When you call insurance company you deal with a private or lance corporeal, you want the general to know they are screwing up. The insurance commission will do that.

JLeslie's avatar

I’m going to expand a little on my answer.

If you get your insurance through the company you work for then your company has a contract with the insurer that they have to perform according to the contract. The benefits director (or might be another title) can help you address the problem.

That’s if you get the insurance through your place of work.

It sounds like you mostly want it fixed and not to deal with a very official route yet. A quick call or email to your benefits department might get something done.

Pandora's avatar

Is you insurance provided through work? If it is I would talk to other workers to see if they have the same issues. If you get enough people to file a complaint to your HR or union, then they can look into it to see if the insurance company is defrauding clients and they can threaten them with going with another insurer. I had an issue like that one time with an insurer through my husband’s work. It was partially their fault and how the things were filed but we were pissed because they didn’t notify us in time. We found out about the errors after a year and a collection agency tried to collect them. My husband thought let us just pay it by I was pissed after making several phone calls and found out there was some back and forth but ultimately the insurance company just decided not to pay instead of notifying us. They said they only needed to notify the dr. office and it was their job to notify us. So we asked around and found almost everyone was having this issue of nonpayment. So a complaint was lodged with the union and the insurer was forced to make payments. At the end of the contract, they were dropped and another insurance company took over.

I almost forgot. One of the issues was we had 2 insurances but only one would pay for his medical procedure. The job one was supposed to pay because he had premium coverage the other did not.

JLeslie's avatar

I asked my husband and he said if an employee had a billing error multiple times, a benefits staff member would definitely follow up on it. My husband is Director of Compensation and Benefits, and previously has been VP in other companies.

seawulf575's avatar

Reach out to your state DHHS. There is usually a page for filing complaints. I ran into this where the medical billing company would randomly change the amount I owed, would charge me more after I paid, etc. I did like your wife and called and complained endlessly. I finally reached out to the state, writing both the DHHS and my state representatives. It brought more heat on the medical company and I’d like to say it fixed everything, but the real cure was that another health provider bought them out and revamped their billing.

jca2's avatar

My insurance is provided by my employer and they had a unit within the Personnel department which was exclusively for disputes and billing issues. Somehow I got the name and number of someone from the insurance company who was really helpful and if I had a problem I’d call her. Once, one of my doctor’s office staff was telling me that the doctor wasn’t covered by my insurance so I’d have to pay and this helpful woman called the and they still didn’t believe it so she sent them screen shots of the insurance showing that the doctor’s name was on a list of eligible providers.

JLeslie's avatar

@gorillapaws Let us know what happens.

gorillapaws's avatar

Thanks for all of the great answers! Unfortunately the employer angle isn’t really an option in our circumstance, without getting into too many details. I’m in a very small company at the moment.

My wife ended up writing the insurance company a sternly worded letter on her portal. We’ll see if that resolves it, but I think the next steps would be reaching out to the state’s insurance ombudsman’s office or similar as many of you have helpfully suggested.

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