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Insurance Claims Help

Discussion in 'Finances, Work, and Disability' started by bygeorge, Nov 26, 2011.

  1. bygeorge


    I am looking for a good resource for advice/help/guidance with processing and payment of medical bills. Any ideas, forums, websites that offer legal advice, processing advice, resolution/escalation advice would be appreciated.

    My medical insurer United Healthcare has wrongly denied claims for years. United Healthcare is secondary to Medicare, and my doctor does not accept Medicare. For years I have self processed these claims with minimal difficulty. The claims in question are all standard office visits which should be covered at some % (at one time it was 80%, but no more.) With my new Doctor they refused for years to pay some claims and paid others with no pattern or explanation. $1000s in claims are outstanding.

    After numerous submissions, denials, phone calls, over the last 3 years a some of the claims were processed. After no response for their claims service and NO response to repeated phone calls and letters, I wrote the CEO this got their attention. They had made numerous errors, e.g. they wanted info from my Doctor, but sent the request to an address they had not been at for 10 years!

    A few claims have be paid, seemingly erroneously. They also continue to deny payment on some claims because they say I did not submit them with in a 12 month time allotment. I did, and know exactly when.

    I am looking for information to put pressure on them, legally, etc. But to do so I need to know more about my rights, what should be paid, etc. I could search the web, but my energy as is my ability to handle stress is very limited.

    Thank you
  2. Hope123

    Hope123 Senior Member

    As you might already know, many insurance companies make money by denying care so if it seems like they are not doing what they should be doing, although some of it might be due to clerical error I would not be surprised if what some of what they are doing is purposeful. I am presuming you are in the US; if not, what I write might not apply to you.

    The more expensive options you have include actually hiring a private care or case manager to take on your case [google for the term] or hiring a lawyer who handles health insurance claims [ask state bar association for some ideas]. The former are paid healthcare advocates who come from a variety of backgrounds including nursing, social work, etc. You can find them sometimes by calling senior center or local/ state/ non-profit agencies that serve the elderly since the elderly often need these services.

    The less expensive would include contacting your state's insurance regulatory agency and asking for help, checking out the legal site Nolo.com, and asking your local librarian for help.

    In fact, calling/ visiting the local library can help you find a bunch of resources for your situation, including books/ websites that specifically address insurance claims written for the lay public.

    Finally, anything you send to insurance companies need to be well documented -- e.g. snail mail needs to be certified mail with return receipt so you have proof of dates.

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