I tell my children, "If you learn nothing else from me, please, never pay a medical bill without first knowing you really owe it." With a child who averaged 3 visits per month to the pediatrician her first year of life with chronic allergies, ear infections, immune system problems and eventually a diagnosis of sjorgrens as well as my own chronic illness, I've had a lot of experience "fighting" with insurance companies for the benefits we pay for.

Over the years we’ve had many different insurance carriers, and I have yet to find one company who pays their claims correctly 100% of the time. With medical costs rising and our family's frequent utilization of these services, it is vitally important to our family budget that we get the benefits we pay for with our outrageous premiums.

Being a registered nurse has helped me to have the confidence to stand up to these big companies, but it doesn't take a medical professional to fight this battle. It is my hope that some of the lessons I've learned over the years can benefit your budget as well:

  • READ your policy.  You have to know what your benefits are in order to fight for them. If there are any exclusions or limitations, you have to know what those are. Some policies require that you see only a certain group of physicians or have your laboratory services done only at particular facility. If you go anywhere else, they may deny or pay a reduced benefit.
  • Understand the lingo. Most of the time the policy contains a glossary of terms if you run across a word that is not familiar.
  • Know who your providers are. Do not rely on the physician's receptionist to know if they are a provider; call your insurance and ask. They may mistakenly think they are a provider, but when the bill comes, you find out they are not. Guess who pays then? Hint: it's not the receptionist.
  • READ your explanation of benefits (often called an EOB). This is a statement from your insurance carrier that describes what they are paying on the services you have received. Go over this statement with a fine-tooth comb. Make sure you are receiving all of the benefits you are entitled to. If there is any question in your mind that something has not been paid correctly, call the insurance company and ask for an explanation and then demand that the claim be adjusted.
  • Do not take "NO" for an answer. So many times I have had to ask for a supervisor to help me. I have had customer service people make up some crazy explanations as to why my claim wasn't paid correctly. Sometimes it just takes asking for a supervisor to get the claim adjusted correctly.
  • File an appeal. If you are still not satisfied with the way your claim was handled, or the customer service person cannot help you, then file an appeal with your insurance company. One example: a claim for an emergency room visit over a holiday weekend was denied because it "wasn't a true emergency." My appeal explained my daughter's medical history and immune system problems: any sign of infection could turn into a hospital stay and a life threatening illness if not treated promptly. My claim was then approved. In all the years of fighting with the insurance companies, I have never had an appealed claim denied.
  • Keep a written documentation of your conversation. With this documentation include the day, the time, and with whom you spoke. Most of the time, conversations are recorded. I once was able to get several claims paid because I had called to ask if a certain physician was a provider on our policy. I was told he was, but the claims were denied because in the meantime, he failed to renew his contract. They were able to review our recorded conversation, and all of the previously denied claims were paid.

It is my hope that armed with these few suggestion you feel ready to win the health insurance battle and keep your health care costs under control.

This has been a guest post by Sherrie from Vian, OK
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