If you have the luxury of ignoring the quagmire that is insurance reimbursement today, then more power to you! If you need to get some of your money back, then read on.
The employees of your medical insurance company are there to help you, and the vast majority of them to their best to do that. They really do! However, their management and owners seem to want to do everything they can to make processing your claim difficult if not impossible. After all, if they don’t pay, they get to keep your premiums. And the premiums of millions of others like you. For example: dates at my insurance company (which shall remain nameless) are kept in the Julian calendar. You know, 1st day of the year, 2nd day of the year…200th day of the year, etc. How helpful is that? When you call and ask about a claim, the first thing your helpful customer service representative may well have to do is translate the date from Julian into a conventional month/day calendar that everyone else uses! Ever submitted claims to your insurance company, maybe even multiple times, only to never ever hear from them regarding that doctor or that claim? Maybe you even faxed the claim so you would know exactly when they received it? But did they get it? Not according to your helpful customer service representative! She never saw it because it went into the big bit bucket in the sky after the bits left your nice computer-fax setup. I have no idea how the physical mail is lost. But I promise you it happens all the time.
Here are some steps you can take to make your time processing insurance claims really count:
1. Keep copies of everything you submit, preferably electronic copies. This piece of advice is basic but easy to ignore when you’re busy and you have your hands full dealing with the medical needs of your family. I used to submit original copies of doctors’ statements to my insurance company whenever I got around to it, blithely assuming they would find their way to the right person and magically get paid. Ha! When I finally looked back, I found that about 80% of the claims I submitted to my insurance company over the past couple of years were never acknowledged by the insurance company. 80%!
2. If you can, use a multi-function device (fax, printer, scanner) and a photo editor such as photoshop. I have found this combination to be very valuable. Now I can easily scan, store and fax claims all electronically.
3. Organize your physical claims into two folders: To Be Submitted, and Pending Reimbursement. Tell your family members to put any new claim forms into the To Be Submitted file. Organize your Pending Reimbursement claims by provider and date. This will be very helpful later as you reconcile correspondence from your insurance company with the work you have already done. Any claims reimbursed or otherwise resolved by your insurance company can either go into an Insurance Resolved These folder, or into a folder containing receipts which you will write off at tax-time. (You will be surprised how many medical write-offs you will get when you begin writing these down).
4. Organize your electronic files into similar folders, but eliminate the To Be Submitted folder. You will be submitting claims as soon as you scan them, so I believe you will find as I did that you have no need for a To Be Submitted electronic folder.
5. Budget your time. You must strike a balance between being interrupt-driven (processing every claim as soon as it comes to your attention) and processing a large number of claims at once at a large interval, like each year or every few months. You will have to process your claims more frequently than once a month, because your insurance company purges the queue of incoming faxes monthly. If you spend 8 hours getting claims just right and submitting them but you call 31 days later to make sure they were received, all your work will probably be lost. So mark your calendar to work on insurance paperwork once every three weeks. If you are a procrastinator like me and might be likely to delay working on insurance even if it’s on your calendar, then mark it every two weeks or every week. If you keep on top of the work, it won’t be burdensome. Work no more than two hours at a time. If you need more time, add an insurance day on your calendar and get back to it then.
6. Make sure your scanned claims are quite legible. Faxes come through at my insurance company very dark so that what looks perfectly fine to me looks nearly impossible to read at the customer service desk. After scanning I sometimes use photoshop’s Image-Adjust-Threshold adjustment to take the noise out of scans. This is particularly helpful if I have scanned a colored carbon copy of a claim form.
7. Make sure your insurance company member ID is on every page of every claim you submit. If your member ID is not on your doctor’s claim form, then add it either electronically (I use photoshop) or physically with a dark felt-tip pen so it will not be missed. When faxes come through at your insurance company, pages routinely get separated. You do not want the processing of your claim to be stopped because your member number was on your cover sheet and your claim was two pages behind.
8. Make sure your doctor’s EIN number is on the claim form.
9. Make sure your doctor’s license number is on the claim form.
10. Make sure the patient’s name is on the claim form and also on your cover sheet.
11. Make sure your doctor has included a valid diagnosis code and a valid procedure code. For autism-related claims, you will find the insurance code guidance at the following website helpful: http://www.talkaboutcuringautism.org/resources/autism-insurance/insurance-coverage-for-biomedical-traditional-treatments.htm. Also very helpful is the following website which lists all of the current ICD-9 codes. If your insurance company is resisting paying because the diagnosis code or procedure code is obsolete, check the code on this list–it is quite possible they are wrong, and they will respect this source of information: http://www.icd9data.com/
12. Submit your claims by fax, then telephone your insurance company and ask that they “be so kind as to…” find the document in the fax file, print it out, review it for completeness, and submit it for processing. You can telephone right after faxing the claim. It is not the job of the people who answer phones to do this, but if you are nice, they will, and the people or machines whose job it is to print and submit claims for processing nightly don’t always do their job, so this step is key. When you call, they will probably tell you that it takes up to two (three…) days for the claims to get into the system and ask you to call back. Don’t accept this. Explain to them that you just faxed the document, you are particularly concerned about this claim (set of claims) and you need to make sure that it was received into their fax system. If the person you get on the telephone is not helpful, hang up and call back. Make sure that they print the document, review it for completeness, and submit it for processing.
13. When you recieve correspondence from your insurance company, file it in your Pending Reimbursement file together with your claims for that doctor.
14. When you receive a request or rejection from your insurance company, and you are required to re-submit a claim with additional information, make sure that any claim that has been modified in any way is clearly marked “corrected claim”. This will cause the insurance company to review the claim again. This will help you avoid my insurance company’s favorite response, “This is a duplicate claim.”
15. When claims are resolved, file them in your taxes folder for retrieval at tax time. This should make your medical expense accounting relatively painless.