Healthcare Claim Denied? You Might Be Labeled – Troublemaker

Do you remember the couple of health insurance scenes in John Q. with Denzel Washington? "We've recently switched carriers from a PPO to an HMO." Leads to, "It doesn't seem right does it?"

That means, restrictions, less coverage and ultimately a "disapprove this claim" stamp.

Every month we dutifully pay for my healthcare plan.

One change over the years that is a plus is that many healthcare carriers recognize chiropractors as providing valid services. That's a plus for me since degenerative back disease is something that affects me on a daily basis. Usually, just a once a month visit to my chiropractor let's me carry on with daily mobility activities pain free.

Last year my chiropractor provider stopped participating with the sub carrier on my plan. It turns out my PPO carrier subbed out the chiropractor services to an HMO type carrier. It was 80% less reimbursement for 80% more red tape.

Echo that movie line, "We've recently switched carriers from a PPO to an HMO."

The filing for my chiropractor visits was now up to me. The first six months were riddled with mistakes like:

• -       One service representative giving me incorrect information that I could fax in my claims; that's not allowed. It wasted 60 days.
• -       Another service representative claiming they never received 3 months worth of claims forms, another 30 days wasted to resend the forms.
• -       Two visits that were approved had no mailing address on file for me with the check-writing department; I had to push for that information which cost me another 30 days. But now, my mailing address was in their system.

It's the principle I've come to with: I have a legitimate degenerative disease, I pay my monthly fee to my insurance company for benefits and a 6 month history of some of the most mismanaged customer service I have ever experienced.

It was time to fight back and file an appeal and, rather than the sub carrier's timeline and procedure, I copied in the State Corporation Commission from the get go to avoid further delays.

Patiently I waited almost 2 months, and the letter I wanted arrived: "After much consideration, your appeal has been approved and your visits will be reimbursed. Expect your check within 2 to 7 days."

Knowing the history of their timelines, I let 14 days go by before calling the sub contracted carrier and here is how the call went after the cordial hellos:

"So a letter I received stated, your appeal has been approved and your visits will be reimbursed. Expect your check within 2 to 7 days. I've waited 14 days now and there is nothing."

The representative asked, "I'll just need a bit more information from you to help. Can you give me the days of the service you appealed?"

"Certainly," I quipped and read those dates from the paperwork in front of me.

"Oh, those checks were indeed written just 5 days after you received the letter it seems," she cheerily said.

"Let me clarify this please. The checks were written but were they mailed?" I persisted.

"I'm sorry but we don't have that information," was the still cheery reply.

I said good-bye and immediately telephoned my State Corporation Commission representative's name from the letter I received from them. By the end of the day what we discovered is that the checks were mailed – to my doctor! Fortunately, all visits were approved so it was even more than their response letter to my appeal stated.

There is a happy ending to this rant.

And a few lessons I'd love for you to take away with whatever else you discover in this post:

• -       You are the customer with your health care carrier.
• -       There are certain terms to your agreement and if you uphold them, do not accept a denial of any sort.
• -       Persist, go to and go around and go over to file an appeal if your coverage is denied once you have all your documentation together.
• -       Be the troublemaker and stick up for yourself because the health care insurance company won't do it for you.

You must become your own health care advocate.

What lesson are you taking away? Do you have a health care claim horror story? Or hey, in the odd chance you have a wonderfully exceeded expectations experience, would you share that?