When the insurance company always adjusts your claim wrong

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JoniB
JoniB Member Posts: 346
edited April 2017 in Employment, Insurance, and Other Financial Issues

For some reason, my insurance carrier always denies my Herceptin treatment claims saying that they have no proof the treatment is for my type of breast cancer. Only problem is my doctor did send in proof and the insurance company did authorize the drug - it is some problem in their system. So every time a claim is sent in it is denied and I have to get on the phone and try to explain the situation to the claims person. This has sent my anxiety levels through the roof. I finally found a way to get my problem to higher ups and they assured me that I now have a VIP claims examiner and all claims will be forwarded to her. Guess what - the claims are still being denied - I just now have someone higher up to call. So frustrating. I hate to think about others who are not so persistent as me are dealing with. Wondering if I should still report them to state insurance department even though the claims are ultimately paid.


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  • LisaAlissa
    LisaAlissa Member Posts: 1,092
    edited March 2017

    Joni, I'm so sorry you're having to deal with this. Essentially, you're being harassed on a regular basis. I do have several suggestions:

    1. Do you have (or with your care providers can you put together) a copy of the insurance company 's approval letter, together with a list of all of the claims/denials/payments of your various treatments. If so, start having your care provider send that along with the claim, if it is being submitted by mail. If claims are submitted electronically, send a scanned copy if possible along with the claim. If that isn't possible, send a hard copy, then refer to the copy by date sent.

    1. If your insurance is through an employer, consider contacting their HR dept. They are the purchaser of health insurance, and often have more leverage than mere policyholders. They may be able to help.

    2. Since you have a special "VIP claims examiner" perhaps you could arrange to have your claims sent directly to him/her along with the reminder of your claims history.

    3. If it happens again, consider giving notice to the "VIP claims examiner" along with a copy to the insurance company's legal department, that any further denial of these claims will be considered harassment by you, which you, of course, will plan to report to the State Insurance Department.

    HTH,

    LisaAlissa

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  • JoniB
    JoniB Member Posts: 346
    edited March 2017

    LisaAlissa, thank you so much for your reply. I told the insurance company multiple times that I consider their denial of my Herceptin claims to be harassment, so seeing you use the same word truly resonated with me. I will call the insurance company tomorrow and inquire about sending the claim directly to the VIP claims adjuster and will also look into having the hospital send the authorization with the claims - all great ideas. Unfortunately, my employer outsourced their HR department and I don't find them helpful, so that is the only option I won't explore. This has been going on since last April and I only have 5 more claims to worry about - can't wait until this is over! Thanks again for your great suggestions.



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  • peggy_j
    peggy_j Member Posts: 1,700
    edited March 2017

    Sorry you are going through this. It seems like this is a tactic of some insurance companies--don't pay claims and force patients to fight for their benefits. If you have options, like the VIP line or ratting them out to your state's insurance commissioner, I say go for it. FWIW, when I've had problems, I sometimes stopped calling and just wrote letters, so I had a paper trail. If I needed to follow up, I wrote a new letter and attached the previous ones. (then if I contacted and outside source, I had a copy of everything). Good luck. It sucks to be dealing with this on top of everything else.

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  • JoniB
    JoniB Member Posts: 346
    edited April 2017

    So a little update. Almost finished with a year of Herceptin and only three more treatments that need to be paid by insurance company. They actually paid one of my bills without my calling and complaining, although the bill did take two weeks to be adjusted. You would have thought with the extra time they took they would have gotten right. They paid the bill but took out a 20% co-pay, which I would not have questioned except .... the person helping me at the insurance company (not the adjuster, but just someone who helps me because I complained on their social media site) told me they were readjusting an older bill because I should not pay a co-pay for Herceptin under my company's plan. Had she not told me that, I would not have questioned the claim that just got paid and would have accepted the 20% co-pay. So much for VIP claims adjuster - I obviously don't have one adjuster doing all my claims or she would have known I don't have a co-pay. Can't wait for the last claim to be paid as I will then send a letter to my state's insurance department. I don't know  if it is incompetence or the company trying to pay out as little as possible.


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