**This post is an addendum to The Global OB Fee Trap: How to Find and Fight It. It probably won’t make any sense unless you read that first!**
Fighting your insurance company is a pain the ass. There’s no way around it. But persistence pays off and if you fight hard enough you will usually win – whether you’re actually right or not.
In this case, you’re actually right so it should be a little bit simpler. Here’s what to do:
- Have your insurance card, your doctor’s bill (that shows what the insurance company paid and what you still owe) on hand. If the bill from your doctor doesn’t have this information on it, you can obtain it from your insurance company by requesting (or printing out from their website if you’ve set up an account) a claims summary statement. Shoot me a message if you need help locating this information.
- Call the Member Services Center and tell them you have questions about a medical bill.
- When you get someone on the line, save your breath. Give them your member ID number and confirm your birthdate – yada yada yada – before launching into your story.
- When they ask what’s wrong, tell them which claim you are disputing so they can bring it up in their system. Then proceed by confirming facts with them one step at a time – so that they walk themselves into a little trap. Start by confirming that your plan covers all preventative care with “first dollar” coverage as required under the affordable care act.
- Then, confirm with them that routine prenatal visits are considered preventative care. (They should say yes – but if they don’t, remind them that all well-women visits, including well-women prenatal visits, are considered an essential preventative health benefit under the ACA. My insurance rep initially fought me on this one, and then after I insisted, she put me on a brief hold to check with her supervisor. When she came back she apologized for being misinformed.)
- Next let them know that your received a Global OB bill that included the cost of the delivery, as well as the cost of your prenatal visits – and ask them why your prenatal visits aren’t being paid for in full AS REQUIRED BY LAW. When they tell you it’s because of the way your doctor billed them, remind them that according to their own provider handbook (this is true for Harvard Pilgrim, and I bet most other insurance companies, but check with Google) doctors are NOT ALLOWED to bill OB visits separately and MUST use the Global OB code instead. Then piece the puzzle together for them and tell them that if they can’t pay the preventative portion of your bill in full, and they won’t let your doctor bill them differently, then they are breaking the law. Tell them that you would prefer not to get your lawyer involved, but that you will if you have to.
- When the rep gets exasperated (and likely confused – they probably don’t understand the system) they will probably tell you they’re sorry but there is nothing they can do. Be sympathetic, but firm. Remember – there really is nothing a front line member services rep can do. Their hands are tied and you don’t need to shoot the messenger. Tell them that you understand they can’t do anything personally, but that you feel strongly about this and would like to speak to a supervisor. They’ll resist this is long as they can. Just keep repeating yourself. If they really resist, use phrases like: “If I can’t speak with someone who can handle this directly, I’ll have my lawyer contact you via certified mail” and/or “I really would like to resolve this on my own, but if I need to file a claim with the state insurance commission, I will.”
- You will probably end up either being transferred to a supervisor (in which case repeat steps 3-7 until you get someone on the phone that can actually reprocess your bill) OR they will tell you they’re going to “look into it” and call you back. If that’s the case, ask for the representative’s name, direct phone number and when you should expect to hear back.
- If you don’t hear back in the specified time frame (you won’t), call back and ask for the status of your claim. Call every day until you get a response. Remind them each time that you intend to fight this claim in court if you have to. Use the word lawyer, use the word insurance commission. DON’T BE INTIMIDATED. Insurance companies win these battles because they wear people down. Be a
beemean-ass wasp in their bonnet. Pester them incessantly until they eventually throw their hands up and reprocess your bill. It took me almost 3 weeks, but they did eventually give in.
- Remember, the goal is to have your bill reprocessed so that the preventative portion is paid in full, and the diagnostic portion applied to cost sharing. If they ask “what do you want/expect us to do about it” tell them that. You can also share with them that other insurance companies (United Healthcare) are using a percentage basis to pay out Global OB claims, with 44% being considered preventative and 56% considered diagnostic. This can help them to realize that this is an actual issue other companies are having to deal with and not just some nut job on the phone making shit up.
- All in all, try to keep your tone polite but firm. Don’t freak out and yell because then they’ll write you off. And if after weeks of persistence you still aren’t seeing results – file a complaint with your state insurance commission. Here is the link to the Maine Insurance Commission – but if you live in another state you can Google it or ask me and I’ll find it for you 🙂
I know this seems like a LOT of work (it is). But it’s worth it. Because if enough people do it, eventually they’ll have to change the system. And if they change the system that’s a lot of dollars we will have collectively kept in our pockets. And those dollars pay for diapers, ok? They prevent shit from getting all over your house.
So if you don’t like shit, then just do it. Basically.