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You Are Your Most Effective Advocate

 

In developing benefit plans and reporting inappropriate actions of insurers, the patient is often the most effective advocate.  The main area of oversight of Departments of Insurance around the country is to protect the consumer (the patient).  Employers have a vested interest in ensuring the health and safety of their employees.

At Cole Pain Therapy Group, our billing staff takes steps to ensure that the appropriate claims are filed in a timely manner and to the company responsible for payment.  Initially, we contact the patient’s insurance company to request a quote of chiropractic benefits according to the patient’s specific plan, and as well, verify the claims mailing address.  Any information we receive from this quote of benefits is recorded, including the name of the customer service representative and the date and time of the call.  However; on occasion, we are given incorrect benefits by the insurance company representative.

In addition to an incorrect quote of benefits, insurance companies will, on occasion, process claims incorrectly.  Our billing staff is trained to look for these inconsistencies upon our receipt of the explanation of benefits.  When we find claims that have been processed incorrectly by the insurance company, a member of our billing department will call the insurance company to bring this to their attention and to request re-processing of the claim.  Again, we record the details of the conversation, including names, dates, times, and reference numbers.  Despite our best efforts to advocate for our patients, it is not always effective.  However, as the patient, and health insurance plan member, you are a much more effective advocate.

If you have a claim that an insurance company has been processed incorrectly, we recommend that you call your insurance company to get the claim re-processed.  Otherwise, you may be responsible for the amount indicated on the original explanation of benefits.

Here are some helpful tips when calling your insurance company:

  • Have your explanation of benefits copy in front of you.  Highlight the date of service, provider name, member ID information, and the incorrect portion of the EOB.
  • Have note paper ready to record the representative’s name, the date and time of your call, and request a reference number for the call.
  • Explain clearly that your claim was not processed according to your benefit plan, and that you expect the claim to be re-processed correctly, and within a timely manner.
  • Ask for a date of when they expect to re-process the claim.
  • If they are uncooperative or give invalid excuses for re-processing, let them know that you intend to forward all the information to the Tennessee Department of Commerce and Insurance for investigation.
  • If you do have to ask for help from the Insurance Commissioner, make sure you are prepared to submit copies of any necessary explanation of benefits, a description of your complaint, and the names, dates, and time information described above.

We are happy to provide you with any necessary documentation for your pursuit, and help in any way that we can; however, payment of the claim is ultimately the responsibility of the patient.

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