Fixing Problems, Claims, Bills and Medicare Issues

We frequently receive phone calls from individuals who are totally frustrated with their insurance companies. Very often, their problems are easy to solve, but it appears that the minute we get an explanation from an insurance company with no check or no notice that the provider was paid directly, people get upset and don’t know what to do next. Here are a few examples:

One person called because she has been insured for many years under a group plan through her employer. Her employer changed insurance carriers and her claims were denied stating that she had a pre-existing condition. When you have continuous health insurance, with no gap in coverage, there is no waiting period for pre-existing conditions. All she had to do was prove to the new insurance carrier that she was continuously insured. As soon as she furnished proof that she was insured for the last twelve months, we advised her to call the insurance company and ask them to reprocess the claims. Simple fix.

Another person covered under an HMO plan called in a state of panic because her explanation of benefits said her identification number does not exist in their system. We asked her to pull out her ID card and compare the number on it to the ID number on the explanation of benefits. Sure enough, the two numbers were not the same. A simple phone call to the HMO carrier, giving them the correct ID number fixed the problem.

Did you ever receive a notice from a collection agency about one of your medical bills? You thought your insurance company was handling the claim and the next thing you know a collection agency is sending you threatening letters. The first thing to do is call your insurance carrier and ask them if they have a record of the claim. They will need the name of the provider, the date of service, and the dollar amount. All too often the provider has not submitted the claim to the insurance company and it ends up in the hands of a collection agency. If your health insurance is utilizing a network, and if you are using a provider in the network, it means the provider must submit the claim to the insurance company.

The next example I would like to share with you is a little more complex, but we are getting more and more calls this summer about this problem. It pertains to snowbirds. Mom and Dad spend the winter in sunny Florida or Arizona and then come back to New Jersey during the summer months. Yesterday we received a phone call from a gentleman whose mother has been doing this for years. She spends six months in Florida and six months in New Jersey. When she was in Florida she was switched to an HMO plan. They made it sound so simple and so wonderful because she would get vision care, eyeglasses, and even some prescriptions. Everything was fine until she moved back to New Jersey for six months. Mother ended up in the hospital. It was not a life-threatening situation and her HMO said that they will not pay. Some HMO’s will pay if you are outside of your referral area and some will not unless it is a life-threatening situation. If you are a snowbird, and if you have an HMO, make sure you read the contract and understand what happens if you are out of your local area. If you are the adult child of a snowbird be sure to inquire what kind of health insurance they have so that your parents (or you) don’t get stuck with a huge medical bill.

This person was pretty upset because he had no idea his mother canceled her AARP Medicare supplement and switched to an HMO. He wanted to know how to get his mother back into Medicare. It is simple. You call the HMO and tell them you would like to disenroll. They will send you a disenrollment form and when they receive it they will notify Medicare. It usually takes about a month. At the same time you should be exploring the costs of a Medicare supplement to be effective the same date you get back into the Medicare program. This is certainly advisable for people that do a lot of traveling or spend time living in different parts of the country throughout the year.

Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.

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