Insurance dispute question

Always--always--question and fight when dealing with insurance companies and doctors' offices. However, people who have worked in the insurance industry say that you can get a LOT farther when you're being nice than when you're screaming and yelling and hostile. So be very nice, but keep pushing.

You need to call your doctor's office first and ask them why they're billing you for the full amount when the EOB from your insurer states that you only owe a third of that amount. Chances are, they sent out the bill before they received payment from your insurer. If they insist that you owe them the full amount, tell them that you want to send them a copy of your EOB, which will show that you don't owe them that much. If they say that they haven't received payment from your insurer, ask them to resubmit your claim.

If your insurer EVER denies one of your claims, call them and ask them to explain exactly why they've denied it. Ask if the diagnostic code is correct. (I've had claims denied because the doctor's office put the wrong code on the claim--for example, using a code for a condition--instead of Crohn's--for which the treatment/procedure isn't recommended.) If they tell you that there's a coding problem, ask your insurer to tell you very slowly exactly what the problem is--and write it down word for word. Then call your doctor's office, read them what the insurer said, and ask them to correct the error and resubmit your claim.

It's standard practice for an insurer to deny almost any claim, in the hopes that the patient will just shrug and pay the whole amount. They'll almost always back down if you call them and--again, very patiently (and being upset and concerned, rather than furious)--question them. But, in your case, the insurer is indicating that they've agreed to pay for 2/3 of the claim. So you need to speak with your doctor's billing people to let them know exactly what your insurer has told you.

This constantly stressful, screwed up health care system is why we need legitimate health care reform. NOW.

Good luck!

I hate to admit doing this, but I've even gotten prompt attention from insurance companies by crying. Tears of frustration after I'd spent a whole day talking to various people all over the country, trying to get them to pay for a treatment they had pre-approved. The person I was crying to promptly gave me the number for someone who really could help me.

One of the problems is that they try very hard to keep you from talking to anyone who can change a bill or make a decision.

I believe (and I may be wrong as I'm only speaking from my experience) that if your insurance isn't paying any of a claim, you are responsible for the total amount billed, not the reduced rate the insurance would normally pay. This is how my insurance works. Also only the amount that you actually pay is applied toward the deductible. For example(IF it works the way you are thinking it does) if the drs office bills you $100 but the insurance company reduces the bill to $50 .. only $50 is applied to the deductible. So you may want to check into that as well because your deductible may not be met if it works the way mine does.

Hope you get it all figured out!!! GOODLUCK!!