Health insurance is scary: The Sequel

Another tale from the claims crypt and what you can do when it happens to you.

Oct 08, 2024

October is a month. Not just because Douglas turns 40 on Halloween, or because Halloween is now a month-long holiday. October kicks off the true start of The Fall Holiday Season™, the fourth quarter of the year, and a sprint towards the finish line of the many promises we’ve made for 2024. Some of the faux deadlines we set for ourselves don’t really matter, but others can impact your health and your wallet in a truly terrifying way.

In the spirit of all things spooky, I’m baaaack to talk health insurance. Again.

With open enrollment lurking in the bushes, you have three months left to use your health insurance benefits in place this year. If your plan has a deductible that you’ve already satisfied, you should be taking advantage of that sweet, sweet co-insurance / co-pay structure and getting all your annual appointments, screenings, and procedures done before your deductible resets again in January. The balance of your FSA account could be “use it or lose it,” too. Buy a new pair of glasses or some teeth whitening kits if you must—just don’t sleep on the pre-tax dollars that belong to you.

Last fall, I told you a health insurance horror story from after I gave birth. I paired my cautionary tale with a solid primer on selecting a health insurance plan during open enrollment. If you’re a newer subscriber, I recommend you go back and read the original. But clearly, my insurance prowess did not shield me from having to face the horrors again.

October also happens to be Breast Cancer Awareness Month, a timely reminder for ladies to squeeze your squeeze in before the end of the year, which I already did. I took care of my annual mammogram and ultrasound in May. Thankfully, they were uneventful in terms of my health, but they awoke the goblins of Big Healthcare to terrorize me once more in a claims battle that spanned months and only just came to a stunning conclusion. I hope.

Yes, readers, it’s time for a sequel. Today, the storyline is the claims process, where many of us get lost in backroom errors and omissions that are harder to work through than that gooey sludge from Stranger Things. Allow me to share what happened this time, how I pushed through it, and what you can do the next time you’re afraid someone got it wrong.

BTW – if you’re short on time and just want the tips, skip ahead to Part Four.

Part One: The Appointment

I’ve been receiving mammograms since my early thirties. My mom and maternal grandmother had breast cancer, and while I’ve been able to confirm I am BRCA negative, I have something like a thirty-times-higher risk of developing breast cancer in my lifetime. These days, this isn’t devastating news—it’s information I’m equipped with to make proactive decisions around screening and surveillance. Lots of women I know are in the same boat and have started before the general recommended age of 40. Despite switching health insurance plans several times in the past decade, I’ve never had a problem receiving coverage, given my family history.

This past May, I went for my annual mammogram and ultrasound. Nothing notable came up. Thank goodness. I moved on.

Part Two: The Bill

Over the summer, I got pinged by my healthcare provider via text and email: review your recent bill now. They were recently bought by an even larger conglomerate than the one that bought them a few years ago. Maybe they bought the conglomerate? IDK, and I don’t care, aside from the fact that appointments are harder to book, and real people are harder to find.

I logged in. The portal had limited information, but it appeared to say my screenings weren’t covered. But when I clicked to learn more, I saw the bill was actually in reference to my mammogram and ultrasound from April 2023. The claim for 2024 was still pending, but I owed around $190 for 2023—a whole 16 months later.

In the messaging portal, I wrote to the billing specialist at my provider’s office. She gave me some canned response about consulting my health insurance carrier about what’s covered and not covered. I thought, oh man. We’re doing this again.

Part Three: The Battle

I wrote back in polite but direct terms. I told her, this type of surveillance is covered by my health insurance. I have a family history of breast cancer. My doctor in her office writes the script for my mammogram each year. Something was likely wrong in the way they billed my health insurer. I will not be paying the balance. Also, why a year and a half later? Please call me to discuss.

Surprisingly, someone did. My doctor’s office had been billing my health insurer with no mention of my family history. They used the wrong code, which coupled with my age, triggered the claims to be denied. She apologized, told me not to pay anything for the 2023 or 2024 services, and she would resubmit them.

This was in July. I thought it was over. But I should’ve known that in the horrors of the healthcare system, over’s not over…until it’s over.

In August, the pings returned: your outstanding balance is overdue. WTF. When I logged into my provider portal, I saw both years’ services for 2023 and 2024 denied and an even higher balance suddenly 87 days past due. The office was about to send me to collections, backdating both “invoices” to the date of my 2024 appointment. Now, if you read last year’s essay about what happens when a claims error lands you in collections, you’d know it’s the last place you want to be.

When I expanded the portal window, the explanation made all the sense to me but would probably make zero sense to the average person, which infuriated me beyond reason. My health insurer said I had exceeded this benefit for the calendar year. But I hadn’t. Someone—either my doctor’s office or my health insurer—thought the 2023 claim was being submitted for 2024, too. I couldn’t tell whose fault it was, but I knew I’d have to get two live humans to connect and sort it out. This was no small feat. I needed to be less polite and even more direct to make it happen.

I wrote back in the portal. I explained the 2023/2024 error. I restated the history of our communications and that I was assured this would be taken care of and resubmitted with the proper coding. I made it clear that I have been contesting my obligation to pay this balance since our communications began, and I demanded for a hold to be placed on my account, thereby preventing me from being sent to collections for an ongoing dispute. I insisted someone call me but only after they’ve called their direct provider contact at my health insurer to get to the bottom of the discrepancy.

I did receive a call. A very nice woman named Stephanie spent an hour on hold with my health insurer. She told me that a claims representative denied my claims by accident, and that now, finally, they should be resolved. I don’t know. It seems to me that they were both to blame at one point, but a real live human finally took the time to fix something she noticed was broken rather than press a giant red “IDGAF” button and kick the problem back to me. Stephanie is a real one. She’s the unlikely hero. And you bet I took down her number, in case this isn’t over.

Part Four: The Lessons

In resolving this latest saga, I knew I had to share it with you. Too many individuals, couples, and families are suffering at the hands of the U.S. healthcare system. Understanding your coverage is just one way to arm yourself against the inequities and incompetencies you could face. It’s equally as important to be able to navigate the claims process.

Here are my tips for the next time the Claims Reaper tries to stick you or someone you love with the bill:

Appeal, appeal, appeal. If I can offer you one main takeaway from this recent debacle, it’s that you shouldn’t accept that first “no” as final when you think it might be wrong. Ask questions. Request better explanations. You don’t need to be an investigator to uncover facts that could result in a different outcome for you.
Use online portals. You might have to wait another business day or two for a response. But you are creating your own written record of what’s going on and steering the narrative in your favor. You might need this trail of breadcrumbs later.
Dates matter. You will receive communications from your healthcare provider and your health insurer. The timing of those communications isn’t always aligned. For example, your health insurer might send you snail mail explaining a benefit, but by the time you receive the letter, you’ve already appealed online. Check dates on everything and put together your own timeline of events.
Coding is everything. If a claim gets denied, ask your healthcare provider to double check how they coded the service you received. This was the root of my two biggest claims issues.
Be forceful, not hysterical. You want to write and speak with authority. Be sure you are directing the person on the receiving end of your communication to do something. Don’t just vent. Don’t use inflammatory language. They still have to want to fix this for you.
Take names. And numbers. There is more anonymity in this process than there should be. Ask for the full names and direct lines of the people you speak with so that you can follow up with them directly.
Avoid collections. This seems obvious, but once you get sent to collections, you are in an abyss that makes solving the problem much, much harder. The people you must deal with are even further attenuated from the claims process, and they don’t really care what happened aside from collecting the money they are told that you owe. Also, of course, it can impact your credit.
Don’t ignore this. I know this can feel very overwhelming, and it’s easier to bury your head in your pillow and hope the nightmare will end. But a scary claim won’t go away with magic—just diligence.

Have any health insurance horror stories for us? I’ll grab the popcorn.

Our family made its annual pilgrimage to the Traveling Spirit Halloween store, which now occupies a defunct discount retailer in a strip mall near home. I’m pleased to report that we managed to stay well within our Styrofoam Tombstone Budget by increasing our Gauze Spiderweb coverage. Follow us for more Halloween tips.

TJA in the news!

For CBS News, Douglas weighed in on whether people should consider refinancing their mortgages this October due to falling interest rates.

He also spoke with CNBC about using cash wedding gifts as a down payment on your first home.

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The content shared in The Joint Account does not constitute financial, legal, or any other professional advice. Readers should consult with their respective professionals for specific advice tailored to their situation.