If you’ve reached your deductibles, chances are you’re thinking about trying to squeeze any last minute medical appointments and procedures into 2007. While you’re doing this, take a quick look through your claims for the year. Our insurance company makes this simple to do via the internet. But you have to understand what you’re looking for/at.

For example, we have a claim that keeps appearing and then disappearing from the company’s computer system. It’s a claim from last December (that’s right…last year). It’s a huge amount of money, and I have a pre-authorization letter. I should have been more aggressive in the spring and really push this issue. But I’ve called a total of six times on this claim. For the first four months after filing, they successfully stalled me by insisting that they needed more information from our provider about the location of service and her clinical notes. Each time, they requested something slightly different. Finally, I obtained an entire copy of our clinician’s file and faxed it to them myself. Then the claim mysteriously disappeared from the computer system. When I called in June they said all was well and it was in process. Then, frankly, I forgot to look again until October, when it wasn’t showing again. I called and the woman said there had been a “huge mistake” and it would be expedited within the next 5 days, which means, in real time, that I needed to wait another 3 weeks and call back. She told me to call back November 16. Well, November was a blur, with LuLu being hospitalized, so last week was when I called. Guess what? Absolutely nothing had been done with this claim that they person I talked with said was denied because we failed to send in the proper documentation. Because I had my own “documentation”, I gave her the list of times we’d called and responded, and miraculously she suddenly found all this paperwork, and again told me it would be expedited in 48 hours, which in real time means that we should have our claim processed by December 27.

So, after speaking with a supervisor about filing a formal complaint, I’m giving them until December 27 to clear this up or I’m contacting the State Insurance Commissioner (which has expedited situations in the past).

Meanwhile, I noticed that they paid a claim from a doctor that they usually deny. Suspicious, I investigated and discovered that it is a coding problem. So, I’m calling the doctor’s office today to ask for new receipts with the correct CPT codes, in hopes of recouping that money as well.

I also noticed another claim is “pending”, and although it appears to be coded right, their notes indicate that they’ve asked for more information. Whether or not they actually did, I need to follow up with the doctor’s office and then the insurance company to get this claim moving again.

And, for all the belly-aching I’ve done about the mail order pharmacy, I’ve got to tell you that something that can only be described as miraculous is happening (and I don’t really know why). Since the beginning of November, all the prescriptions we’ve filled, either through mail order or at our local pharmacy haven’t cost us a thing! We have obviously reached some kind of maximum limit. I checked the company’s website over the weekend, and discovered that it has a handle tool where you can plug in the medication and dosage and find out how much it will cost you on your plan. So we’re refilling all maintenance medications for the family before the year’s end. What a Christmas present!

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