"Where Is Our Reimbursement?"
(MONEY Magazine) – Q Last March my husband was treated at an urgent-care facility. Afterward we called our health insurer to confirm that this was covered. (They said it was.) We mailed the receipt and waited to be reimbursed. A month passed, and when I contacted PacifiCare, they said they'd never received it. I re-sent it and followed up twice more. Nothing. Months later, we still haven't seen a check. And the last time I phoned, I was told the claim was denied! Can you help? —Allyson Ranallo, Westlake Village, Calif.
Answer When we contacted PacifiCare, spokeswoman Cheryl Randolph immediately acknowledged that there were things amiss in the handling of your claim. Your paperwork, it seems, fell into a bureaucratic black hole.
See, PacifiCare's Southern California HMO policyholders choose a primary-care physician, who might belong to a medical group. PacifiCare often outsources claims payments to such groups, acting as the intermediary. Somewhere in the back-and-forth, your receipt may have taken a left turn into nowhere.
As for why you were told the claim was refused, Randolph was mystified. Your husband's visit was indeed covered by your policy. According to procedure, denials are supposed to be followed by a letter of explanation, but you never got such a communication.
Randolph owned up to PacifiCare's fault on both counts. "For whatever reason, it wasn't paid," she says, "and we apologize. There probably wasn't enough follow-up on our part." A representative of PacifiCare has since called you to convey this message; you were also—finally!—cut a check for the total bill of $171.
Medical billing screwups happen with appalling frequency, thus it's wise to think of each claim as a potential headache. Trade group America's Health Insurance Plans suggests keeping a paper trail and a phone log. Get the name and extension of each person you speak with and follow through. If nothing happens for 60 days, speak to the next level of supervisor. Climb the food chain until you get someone who recognizes the error. Also, file a complaint with your state insurance commissioner (find yours at naic.org), who may be able to help resolve the issue.
When you're told by phone to resend a claim, ask the rep if he or she will hold on while you fax it. That way, you'll be able to make sure it arrives.
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Reporting By Kate Ashford contributed to this article.