My apologies for this delayed post. Due to Mother Nature's rain/snow/slush/sleet/freeze life has been interesting. AND...I had to call 2 branches of my own insurance company today.
So...how to make friends with your insurance company. First, as I said before, know what your coverage is and what it allows, as much as possible. Not only does it answer many of your questions, but it gives you a starting point if you do need to call the company.
By the way, in case you are wondering: if the company says your call may be monitored, rest assured that they are taping all calls; sometimes senior employees are also "listening in" to calls to make sure employees are doing and saying what they should be doing and saying. It's just a nice way to saying that you are being taped. Taped calls are also randomly audited, to check on employee accuracy and politeness.
(Star Wars Death Star Music)
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[This assumes this is your first time calling about an issue.]
Before calling, get prepared. Have a working pen/pencil at hand, paper, your insurance card, any paperwork you have that you have questions about. Plan to be on hold, so have a book/game, whatever to occupy your mind. Make someone else take care of the children's needs as much as possible during this time. And find out what hours the Customer Service reps are in (I like to call on Sundays...you get the available hours information pretty fast that way). Generally, the best times to call are first thing in the morning, both weekdays, and, if they have Saturday hours, on Saturday.
Additional note: re: holding and menus: I hate them too.
Hold times can't be helped sometimes. Most places try to keep them under 5 minutes. However, sometimes the fates conspire against you. One time, we had hold times under 1 minute. Then...we had a fire drill. Our phones shut down automatically to incoming calls (we have to say goodbye to whomever we are speaking to and hang up). All calls on hold were routed to our sister office. So, instead of 90 people answering phones, we were down to 30 people answering phones for over an hour. Hold times were dramatically increased, as you can imagine. If the hold time gets too long for you, hang up and try again later - or actually, earlier (see above).
Menus. I hate them. Press 1, say 5, give me your firstborn. If it is something that can be done through the menu faster (I need new cards), I will use the menu. But if I need to talk to a human to get something fixed (like my claims issues this morning), I'll skip the menu by saying "Operator". Generally the menu will then default to a human although you may have to hold to get one.
Call the Customer Service number on your insurance card. Be prepared to give your insurance number information, and other information they may need to identify you (my company always asks me to confirm my address and birth date, sometimes adding home phone number or work number). Then, be polite, calm, and specific about why you are calling:
I don't understand why you denied my claim.
This EOB is asking about other insurance and I have/don't have some/any.
My doctor wants me to have (an X-ray, CT scan, surgery) done and said I need to call about getting approval.
Make sure you write down the name of the person you are speaking with, and the time and date. Make notes as to their answer to your questions. While they are supposed to document all telephone calls, some are more diligent as to how much they write than others are. If you don't understand their instructions or information, ask them to repeat it another way. Make sure to get a call reference number for your notes.
If the call resolves your problem/issue/question, great. You are done. You remained polite, and they remained polite.
Now, what if, some weeks later, something goes wrong. Your claim is still denied, you had the surgery but it's not being paid for, you are being billed for services you don't believe you should have to pay for.
You need to call again. Remain as polite as possible. I well know how frustrating it can be (it took me 10 calls to get an ER bill paid correctly once...). Please don't scream, swear or threaten the employees. Some companies will allow an employee to hang up on a customer if they become abusive, others require the employee to call a senior manager. ALL states/companies take threats seriously these days so don't use physical threats of harm. Continue to note down to whom you speak along with the time and date. If, after another call, things are not corrected, request to speak to a supervisor/senior Call Representative. Again, note down date and time and stay polite.
(A company had a very frustrated woman once state that she would come over and bomb the company to kingdom come. The employee panicked, claimed that there was a bomb threat, and the whole building was evacuated. The police arrived at the woman's house and she spent some time in the police station until things were straightened out.)
If things are still not corrected, it's time for a certified letter. Send copies to your HR people and to the company. Spell out the time and date of all your calls, and to whom you spoke. Note in full the problem and state how you would like the problem to be resolved. Most problems are solved by this point.
Especially note if there are discrepancies in information - I spoke to Susie on X date at Y time, and also John on Z date at A time, before my surgery, who told me I could have my breast enlargement surgery covered by insurance so I had it done, but now my claims are being denied since you don't cover cosmetic surgery. If I had known it was considered cosmetic I would not have had it done. (Yes, this was an actual call. Due to the member being given erroneous information, which she had documented, as did Susie and John, the insurance paid for the cosmetic surgery even though it was not covered under the member's contract. Yes, Susie and John lost their jobs since they hadn't checked the contract information before giving their answers and their job description requires them doing so - John actually just used Susie's answer and never bothered checking!).
Also note if you are given 2 different answers, for the same reason as above. Sometimes people don't check for correct information and this is one way to get things paid for that may not be covered under your contract. However, if you get identical answers and know that's what your contract says, please don't badger for a different answer. That's unfair to the insurance employees AND to your co-workers who play by the rules.
Let's now say, for some reason, that you aren't getting the issue resolved. You/your child REALLY needs this surgery/drug/treatment/wheelchair and you aren't getting it. You know your policy should allow it (one of the worst issues a company has is when a member insists on getting something that their policy doesn't allow. Insurance companies don't want an unhappy member who might sue or go to the media, but they also have a legal contract with your employer so what can they do? The answer to this varies). The time has come for your first level of appeal.
First appeals are reviews of contested denials of service, generally internally, by a board of various people. Boards usually consist of medical directors (doctors who work for the insurance company), lawyers from the legal department, staff from the Patient care areas, and sometimes "members of the public" who are not employees. The issues are reviewed and may be approved at this level (yes we will allow this even though the contract denies it under X circumstances) or they may be denied yet again. Sometimes information is sent out to a separate review board at this level for their opinion. Other times, this occurs at the second level of appeal.
The Second level of appeals. Here's where things get messier. Some member contracts allow 1 additional level of appeal, some allow 2. Some require going to arbitration. There may be costs to you for these levels. Sometimes they are worth it to a member. Other times, they are not.
Generally, a member's last choice is to involve the regulatory commission that controls all insurance work in the state. Others will try to involve the media (letters to the paper, TV, internet). Depending on the issue, again, the member may win or lose. It can take months to years to get through all the levels of appeals. It is very individual, and only you can know for sure what is right for you and your family.
Try to work with your insurance company. You will both be happier.
(And yes, I did get my insurance issues worked out. Yes, it is frustrating, but we all make mistakes. Files don't get updated properly sometimes so you have to call and make sure they do so. Sometimes, it takes multiple calls - one of my coworkers had multiple claims denied for her husband and son because the computer system kept dropping their PCP. She had letters showing she called and the system had been updated, but it happened for nearly 2 years until a system update was put in. It seems the old system had problems with people with the same names in 1 family - John Smith and John Smith junior were seen as the same person, even with 2 VERY different birth dates, and the system couldn't figure out how to assign the PCP so it just didn't. Finally got that fixed.)
(Music fades away...)