Health Insurance Claims Process Is a Nightmare: Even for this 35-year health insurance maven.

On Saturday, April 17th, 2021, I woke up feeling sick. I had hoped I would get better, instead as the day progressed, I fell violently ill.  I finally called Miami-Dade Rescue.  I thought that my time had come!  I was so sick that I was unable to walk downstairs to open the front door. Somehow, I did manage. Though, I collapsed shortly after. When Miami-Dade Rescue arrived, I was semi-conscious and could hardly reply to their questions. I was transported to the ER where they immediately started running blood work, CT scans and MRI’s.   

Thank God all tests came back normal, but the ER Doctor admitted me for further testing and evaluation.  I was in the hospital for three days and then discharged. I was ultimately diagnosed with Vestibular Neuritis an inner ear disorder that may cause a person to experience sudden, severe vertigo (spinning/swaying sensation), dizziness, balance problems, nausea, and vomiting. 

Since I have been in the insurance profession for many years, I was eager to log into my United Healthcare portal to review the claims. Something I highly recommend. I was in shock when I saw that the hospital bill was for $87,000. To my surprise over $15,000 of those claims where denied!  The reason – Out of Network provider.  Meanwhile, the hospital I was transported to by rescue was an in-network hospital, but the ER doctors were not.  

Unfortunately, this is common as most hospitals do not employ their ER doctors and anesthesiologists. Instead, the hospital has a contract with those doctors, which they then bill the patient. In most cases those doctors are not contracted with the insurance companies.  However, the patient can (and should) appeal the claim. Often, it will be reversed and covered or significantly reduced if the patient was at an in-network hospital. 

On July 1st, the Biden Administration issued an interim final rule that restricts excessive out-of-pocket costs to consumers from surprise billing and balance billing. The bill: 

  • Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated as an in-network without requirements for prior authorization. 
  • Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates. 
  • Bans out-of-network charges for ancillary care (such as an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances. 
  • Bans other out-of-network charges without advance notice. Healthcare providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate. 

In an emergency, your number one priority is to get the help you need. However, if the service is elective and pre-scheduled then the patient should discuss and ask questions while coordinating the procedure with the doctor’s office.  Always confirm that the procedure is performed in an in-network facility and preferably at a free-standing facility rather than a hospital. The hospital contracted fees are much higher, and it will be more costly to the patient.    

With the help of our in-house claim’s advocates, we have begun the appeals process. This situation is frustrating for me as someone in the industry, and I can only imagine how frustrating this must be for individuals that do not know how to navigate these issues. This is an ongoing situation, and I will continue to share my experience once the billing issue is resolved.   

In the meantime, I have made sure to make my children aware of all my important documents. I highly recommend that you not pay bills received by any provider until the carrier processes them and reviews them for accuracy.  At that point, you can begin the appeals process if you disagree.  It is essential that you review the EOB (Explanation of Benefits) to determine if the claim was processed correctly based on your benefits.  If you disagree with the EOBs, you can then start the appeal or contact your Benefits Advisor to help you with the process.   

By Ileana Miranda, Employee Benefits Consultant, Sapoznik Insurance, a World Company