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Help with health insurance problems

Old 02-28-08, 01:54 AM
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Help with health insurance problems

I have a sister who is a dental student and purchased health insurance through a company advertised by ASDA. Several of the doctors she's seen late last year for some health problems have had trouble getting their claims received by the health insurance company. My sister claims that some doctors' offices have had to file the claims 6-7 times, and yet when she called the insurance company, they deny having received any claims.

My sister has wondered if there was any way to prove that the claims were being received by the insurance company, even if that meant that she would have to send the claims herself. (The doctors want nothing to do with the insurance company; they say they have sent the claims according to standard procedure, and it's out of their hands now). When talking to the insurance company, they say that all their claims are received at a PO box, and they don't have anyone to sign for them.

At this point, she's afraid that the doctors will send collections agencies after her because her insurance hasn't paid their portion. Both my sister and I are extremely frustrated at how ridiculous this whole ordeal has been. We find the insurance companies' denials suspect, but what we can we do? We're pretty much desperate for any help we can get at this point. Thanks.

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Old 02-28-08, 07:35 AM
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Make sure she is covered for whatever was done by the doctor's and then if she is covered get an attorney.
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Old 02-28-08, 07:53 AM
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tell your sister to call the insurance company and ask them what she needs to send them for the claims. then have her send it registered mail, signature required and return receipt. or by Fedex or UPS
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Old 02-28-08, 08:08 AM
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Originally Posted by iveal
I have a sister who is a dental student and purchased health insurance through a company advertised by ASDA. Several of the doctors she's seen late last year for some health problems have had trouble getting their claims received by the health insurance company. My sister claims that some doctors' offices have had to file the claims 6-7 times, and yet when she called the insurance company, they deny having received any claims.

My sister has wondered if there was any way to prove that the claims were being received by the insurance company, even if that meant that she would have to send the claims herself. (The doctors want nothing to do with the insurance company; they say they have sent the claims according to standard procedure, and it's out of their hands now). When talking to the insurance company, they say that all their claims are received at a PO box, and they don't have anyone to sign for them.

At this point, she's afraid that the doctors will send collections agencies after her because her insurance hasn't paid their portion. Both my sister and I are extremely frustrated at how ridiculous this whole ordeal has been. We find the insurance companies' denials suspect, but what we can we do? We're pretty much desperate for any help we can get at this point. Thanks.

Sounds like both parties could be at fault, I would talk to your sister's benefits person (the person that 'buys' the different insurance plans). Also, I wouldn't be so quick to blame this on the insurance company, I find the doctors saying that its out of their hands, as suspicious. Obviously there are some crossed signals here, and there is no way to determine who is doing what.


One thing I would do (if the only issue is the address issue), Is to send the claims to a physical address, and have it certified with signature. Then call and follow up.


Why don't the doctor's office fax in the claims?

Last edited by superdeluxe; 02-28-08 at 08:10 AM.
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Old 02-28-08, 09:28 AM
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Last I heard, one of the doctor's office won't fax the claim for some reason. I'll have to ask her about that.

Since claims are being sent to a PO box, the insurance company says that no one will be able to sign for them (when my sister last called them). I find this a bit odd. Will registered/certified mail with signature still work? Can the insurance company just ignore the post office notice to pick up the claim? That's been a concern.
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Old 02-28-08, 09:59 AM
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sounds like a no name company that is playing a game

call the state's insurance regulator as well
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Old 02-28-08, 10:00 AM
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Since it is a PO box you can't do FedEx or UPS. You can do Delivery Confirmation which will at least help you if you have to go to court. You can also call and see if there is an alternate address to send claims to, but my guess is that the answer is no.
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Old 02-28-08, 10:07 AM
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If I got that much runaround, I would start calling govt. agencies and local congressmen.

Dont' the doctors contract with the insurance companies whose insurance they accept? If so, shouldn't they be the ones who are doing the leg work on this.
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Old 02-28-08, 10:11 AM
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Originally Posted by iveal
I have a sister who is a dental student and purchased health insurance through a company advertised by ASDA. Several of the doctors she's seen late last year for some health problems have had trouble getting their claims received by the health insurance company. My sister claims that some doctors' offices have had to file the claims 6-7 times, and yet when she called the insurance company, they deny having received any claims.

My sister has wondered if there was any way to prove that the claims were being received by the insurance company, even if that meant that she would have to send the claims herself. (The doctors want nothing to do with the insurance company; they say they have sent the claims according to standard procedure, and it's out of their hands now). When talking to the insurance company, they say that all their claims are received at a PO box, and they don't have anyone to sign for them.

At this point, she's afraid that the doctors will send collections agencies after her because her insurance hasn't paid their portion. Both my sister and I are extremely frustrated at how ridiculous this whole ordeal has been. We find the insurance companies' denials suspect, but what we can we do? We're pretty much desperate for any help we can get at this point. Thanks.

How long ago were these office visits? You usually have a while before they'll send collections after you for non-payment.

She should ask for copies of the Health Insurance Claim Forms that were submitted on her behalf (this is probably how her claims were submitted, if they were submitted by mail and not electronically). She should confirm that her information is correct on the forms (insurance ID number, date of birth, etc). She should also confirm that everything's being sent to the proper PO box (is the PO box printed on the insurance card the correct PO box for her claims, or is there another/an alternate PO box that the insurance company is using-- you should ask the insurance company).

Are the doctors she's been seeing "in network" or "out of network"? (In other words, are they participating providers in her plan).
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Old 02-28-08, 10:35 AM
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Originally Posted by cdollaz
If I got that much runaround, I would start calling govt. agencies and local congressmen.

Dont' the doctors contract with the insurance companies whose insurance they accept? If so, shouldn't they be the ones who are doing the leg work on this.

every doctor has a rule that you are responsible for all charges if the insurance doesn't pay

this sounds like game that a lot of insurance companies play to delay paying claims to make more money by having it sit longer in their bank account collecting interest
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Old 02-28-08, 10:39 AM
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Originally Posted by al_bundy
sounds like a no name company that is playing a game

call the state's insurance regulator as well
Exactly what I was going to suggest: google your state's government insurance commissioner, find their website, and they should have a way you can file a complaint.

Before you do that, though, I would get copies of what the doctors claim they sent the insurance company, as another poster suggested. If you can mail or fax those over to the insurance commissioner, in support of your complaint, the insurance commissioner will investigate. My experience (years ago, but similar situation) was that once the insurance company was contacted by the insurance commissioner, suddenly my claims were processed with great speed.

Good luck. I've had every kind of insurance nightmare you can imagine, and I can imagine your sister's frustration.
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Old 02-28-08, 10:44 AM
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The office visits were 2-3 months ago. My sister was just at one of the doctor's office again today to try to resolve the matter, and they say at this point, they will not refile insurance claims or fax the claims to the insurance company. This particular doctor's office says it's up to my sister to deal with the insurance company now; the doctor's office only cares about getting payment (from my sister). The doctor's office cannot provide any sort of delivery confirmation/proof of delivery/proof of sending those previous claims. They just told her that unless she initiates some sort of payment plan, they will send her case to a collections agency. She has agreed to pay a part just to avoid that.

The insurance company is United Healthcare and appears to be affiliated with Gerber Life Insurance somehow. She heard of them through ASDA (American Student Dental Association). I'm going to take off of work this afternoon to see if I can contact the state insurance regulator and any other government agencies I find in the phonebook that may be relevant.

She now has a copy of the claims from one of the doctor's office and will be getting the rest soon.

This insurance company doesn't discriminate between "in-network" and "out-of-network". They don't have a network whatsoever.

Thanks so much for all the help. It really gives us a sense of hope.

Last edited by iveal; 02-28-08 at 10:48 AM.
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Old 02-28-08, 10:50 AM
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Originally Posted by al_bundy
every doctor has a rule that you are responsible for all charges if the insurance doesn't pay
Yes, but it hasn't gotten to that point, where the insurance company is denying the claim. They haven't (supposedly) rcvd. the claim yet.
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Old 02-28-08, 10:53 AM
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Originally Posted by iveal
The office visits were 2-3 months ago. My sister was just at one of the doctor's office again today to try to resolve the matter, and they say at this point, they will not refile insurance claims or fax the claims to the insurance company. This particular doctor's office says it's up to my sister to deal with the insurance company now; the doctor's office only cares about getting payment (from my sister). The doctor's office cannot provide any sort of delivery confirmation/proof of delivery/proof of sending those previous claims. They just told her that unless she initiates some sort of payment plan, they will send her case to a collections agency. She has agreed to pay a part just to avoid that.
It is now time to raise hell and escalate it. The part about not re-filing sounds like bullshit. It is in their best interest if they want to get paid and keep being affiliated with this particular insurance company.
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Old 02-28-08, 11:34 AM
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Originally Posted by iveal
Last I heard, one of the doctor's office won't fax the claim for some reason. I'll have to ask her about that.

Since claims are being sent to a PO box, the insurance company says that no one will be able to sign for them (when my sister last called them). I find this a bit odd. Will registered/certified mail with signature still work? Can the insurance company just ignore the post office notice to pick up the claim? That's been a concern.

Don't send the claim to the PO box, send the claim to the actual real physical address of the company.

But I would definately follow up with the faxing.
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Old 02-28-08, 11:37 AM
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Seems to me that the doctors office refuses to do any extra work to get payment from the insurance company. Refuse to fax the claims? That makes no sense.
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Old 02-28-08, 11:38 AM
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Originally Posted by cdollaz
It is now time to raise hell and escalate it. The part about not re-filing sounds like bullshit. It is in their best interest if they want to get paid and keep being affiliated with this particular insurance company.

Agreed. I wonder if they even faxed the Insurance company even once.
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Old 02-28-08, 12:47 PM
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Originally Posted by cdollaz
It is now time to raise hell and escalate it. The part about not re-filing sounds like bullshit. It is in their best interest if they want to get paid and keep being affiliated with this particular insurance company.
The problem is that the insurance company doesn't have a "network" of affiliated physicians for my sister's policy. As a result, the doctor probably doesn't care just as long as they can extract payment from somewhere. In this case, my sister has more to lose, so she has agreed to pay a first installment in hopes of getting the matter resolved before she has to make subsequent payments.

I still don't understand why the doctor refuses to re-file or fax the claim. I can understand if they're upset too, but it doesn't seem like much to ask for, especially after my sister has agreed to a payment plan during the interim. But then again, we're not in a position to negotiate ....
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Old 02-28-08, 01:01 PM
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Has this policy ever paid any claims for your sister, or is this basically her first time using this insurance company?

Some policies reimburse the patient directly, i.e. the patient pays the doctor in full, the doctor notes the payment on the bill to the insurance company, and the insurance company reimburses the patient (not the doctor). In such a case, payment would never go to the doctor, but rather to the patient.

Again, the fact that the insurance company says they haven't received the claims is what's weird, but double check who would get paid in the event the insurance company pays the claim (either the doctor, or your sister).
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Old 02-28-08, 01:04 PM
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It takes what, a fucking secretary 5 minutes to get the claim out. Yeah, that's quite a burden.

I'm not sure what city you are in, but you may want to see if you local TV station has some king of consumer investigative team. Give them a call and let them go to bat for you. I have a buddy who is in a fairly significant customer service position at our city's largest energy provider. It has been interesting occasionally talking to him to see how things really work, but he told me that if you want to see "shit get done" and make people at his company start to dance, you call our local investigative teams and your problem will get addressed quickly.

Either way, first make sure the work is actually covered by her policy, and if it is, this may be as easy as filing the claim with them and having them reimburse you instead of the doctor.

Does the doctor's office bill/submit claims themselves or do they have a billing service?

Has the doctor actually told you they will not do anything further or is it just the office staff?
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Old 02-29-08, 12:09 AM
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This is what I currently do for a living so I will offer what I can.

UHC is one of the worst. I deal with them on a daily basis and it is a constant battle with them. They have been accused and I believe sued in the past for destroying the claims at the end of the day that the employees don't get to. Even after switching to electronic filing we still have issues with them telling us they didn't receive the claim.

If the doctor isn't contracted with UHC, then ultimately it will be up to your sister to pay the claim at which point I would make sure she is paying at private pay prices and not the insurance price. Most doctors have two different amounts due to the fact every contract pays differently so they have to set their insurance price high enough to cover all contracts.

We do have a similar policy in our offices for non-contracted insurances. We will file a claim a couple of times but after that it is patient responsibility. We have enough issues fighting to get payment from insurances we are contracted with to bother chasing down payments from non-contracted ones. I think the last time we did a report on it and something like 40% of all claims are paid wrong with 90% of those in the favor of the insurance companies.

If the doctor refuses to file another claim, I would request a completed claim form from the doctor for every date of service so you can fax it yourself. Once it is completed it doesn't matter where it comes from. Keep in mind UHC at least in Florida has a timely filing limit of 90 days which means if it is past 90 days you will also need proof of timely filing for each claim. This can be as simple as a screenshot showing the appointment info along with the date a claim was printed/generated.
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Old 02-29-08, 01:03 AM
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I managed to get a copy of the claims from my sister today. I'm completely clueless, but I think the doctor's office filed the claim incorrectly.

On the back of my sister's insurance card, it references Emdeon ID 74227 with claims going to a Dallas, TX 75380-9025 address. However, all the claims from the doctor's office have a payer ID of 87726.

I googled Emdeon, 74227, and 87726, and I feel those numbers are the Emdeon numbers for submitting a claim. 87726 is associated with United Healthcare certainly, but 74227 is not. However, 74227 refers to "Mid-West National Life Insurance Co. of Tennessee - Student Insurance". I am guessing that the office staff looked at the front of the insurance card, saw United Healthcare, looked up United Healthcare and used the Emdeon 87726 associated instead of the Emdeon provided on the back of the card.

So is this the fault of the office staff for not filing the claim correctly? It would explain why the insurance company didn't receive the claim. But the doctor's office told my sister today (before I discovered this Emdeon thing) that they won't refile. Is there anything we can say to convince them to have another look? They seem to be pretty fed up with the entire situation, and based on innocentfreak's testimonial about battles with insurance companies, I can see why.

Thanks so much.
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Old 02-29-08, 08:16 AM
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Yeah sounds like one of the issues we deal with a lot with new office staff.

87726 is the default electronic payer ID # for United so the office probably looked and saw it said UHC so it just used the usual claims address which is why there are no claims on file. Of course in her case the network is UHC but the administrator is a third party so all the claims have to go to the third party, which in this case would be the 74227.

I would definitely lay blame with the office in this case. I would call them or have your sister call them since with HIPAA unless she has you authorized they won't be able to talk to you about her bills. I would ask to speak to the office manager since at least in our offices you won't be able to speak to the doctor over the phone and they don't handle the filing anyway. I would ask them to verify what claims address they used to file the claims and when they tell you PO BOX 740800 or whatever one they used, I would point out that isn't the claims address on the insurance card. I would then ask them to refile one last time to the claims address listed on the back of you card which they should have a copy of the card on file in her chart.

If they refuse I would request copies of the claims with the correct claims address and insurance info on the claims so you can file them yourself with the correct information.
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Old 02-29-08, 04:04 PM
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Well, my sister called the doctor's office again today to ask if they would care to refile under the correct Emdeon payer ID. No go. The office claimed that the claims all go to the same place despite the different Emdeon IDs. The lady in the office said that the claim was previously denied by Pacificare, which is parth of UHC, because lack of coverage. I'm more inclined to believe that the claim was denied because it wasn't sent to the proper place.

Now it's up to us to send the claims in. So what sort of documentation exactly should we be looking for? There appears to be electronic logs of previous claims to the incorrect Emdeon ID amongst the paperwork too.

And by the way, is there any way we can file a complaint with some sort of consumer protections agency to have the doctor's office reprimanded? If not for the loss of anonymity, I'd feel that reporting this situation to the local news would be helpful for future patients to avoid this doctor.
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Old 02-29-08, 04:39 PM
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Originally Posted by iveal
Well, my sister called the doctor's office again today to ask if they would care to refile under the correct Emdeon payer ID. No go. The office claimed that the claims all go to the same place despite the different Emdeon IDs. The lady in the office said that the claim was previously denied by Pacificare, which is parth of UHC, because lack of coverage. I'm more inclined to believe that the claim was denied because it wasn't sent to the proper place.
By that statement alone, that tells me they don't know what they are doing. You have to use different payer ID numbers for the most part except in rare circumstances, of which UHC isn't one of them.

Originally Posted by iveal
Now it's up to us to send the claims in. So what sort of documentation exactly should we be looking for? There appears to be electronic logs of previous claims to the incorrect Emdeon ID amongst the paperwork too.

And by the way, is there any way we can file a complaint with some sort of consumer protections agency to have the doctor's office reprimanded? If not for the loss of anonymity, I'd feel that reporting this situation to the local news would be helpful for future patients to avoid this doctor.
You will need a completed claim form most likely a HCFA-1500 completed which if they gave you everything you should have an orignal or they could print you one which will include the doctor's name, address, place of service, CPT/procedure codes and ICD9/diagnosis codes along with all her insurance information. Then I would just contact the insurance on your card and ask if there is any way you can fax your claims in since the doctor's office can't seem to get it right and refuses to call themselves. Hell maybe you can get the insurance company to call the doctor's office on a three way. Keep in mind with the regulations your sister will most likely have to call.

One other thing you could also do is request a copy of the denials the office received. If they are telling you it is due to lack of coverage, I would definitely ask to see a copy. Then again if it is an electronic rejection it won't show much and in fact would show the same thing if you filed a claim with a wrong ID to UHC, at least in our system. It just generates a generic denial stating no coverage found for the patient whether the patient truly has no coverage or the patient just is no where to be found in the database.

Beyond that I don't know what else to tell you. Unfortunately it sounds more like you are battling an office where the staff makes the rules and the doctor just lets them. One thing you could always try is make an appointment for you and your sister to see the doctor so you can sit down and discuss it with him. Then again if the doctor is just an employed physician he probably won't be able to do much, but if he owns his practice he might be able to help you with this.

If you have any other questions feel free to ask.
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