Fighting with insurance, part 2 — getting real

Yes, you may have to sit down with a hefty document if you want to fight your health insurance company. | Photo by Scott Graham on Unsplash

Hey there —

Recently, a buddy called me with an insurance problem. (This happens when you make a podcast about the cost of health care.)

His wife fell and broke her shin bone in multiple places while they were traveling. Repairing it required complex surgery — and general anesthesia, which meant the hospital had to keep her overnight.

When the hospital bill arrived, my friend’s insurance company was like: Overnight hospital stay for a broken bone? Nope, we’re not covering this.

My friend left a fairly urgent voicemail: What am I supposed to do? Hire a lawyer? They say I’ve only got like 30 days to appeal this. 

And the first line of defense stuff (meaning, most of the advice we gave you last year – asking questions, setting aside time to deal with the problem, etc.) seemed unlikely to cut it.

I gave my pal a road map, which I can now pass along to you.

I told him: You’re gonna go down these three routes, in this order.

Route One: Get your doctor on the case

They’ve probably heard about this exact problem a bazillion times. And if you’re lucky, the doc will say, “Yep, I hate it when they do this, but I know exactly what to do.”

And if you’re especially lucky, your doctor will take care of it — get on the phone with your insurance, or file an appeal. I talk with a lot of doctors who say they do this. All. The. Time. It sucks for them (fighting with insurance isn’t what they went to med school for or how they like spending time), but they do it.

A little less lucky, they’ll tell you what to do — what forms to file, maybe give you a number to call — and they’ll back you up. 

Route Two: Call in your HR department

We talked about this strategy in part one, but it’s worth repeating here. 

My buddy and his wife have access to a well-functioning human resources office. That’s a pretty big privilege. If you’ve got that too, ask HR to take a look at your denial.

As I told my buddy, if they offer to help, don’t take anything for granted — especially if you only have a certain amount of time to appeal your claim. Ask them: When should I expect to hear from you about this? Or maybe better: How about I get in touch with you in a week, to see how this is going? 

And if that conversation is a phone call, follow up with an email, of course. 

Route Three: Get ready for war. Check your arsenal. 

You build your arsenal from the content included in your insurance plan document. And that document is not the little chart you saw when you chose insurance — the one saying how much office visits cost, how much for meds. 

This is a long PDF, at least 80 pages, and it’s a legally-binding contract. It says exactly what your insurer pays for, under what circumstances.

And you’re legally entitled to a copy of it. 

It may be on your insurance company’s portal or your employer’s HR site. It may be labeled “plan document” or “benefit booklet” or “benefits information” or “other information.” And if you don’t find it in any of those places, call your insurance company.

Going through the thing is obviously a big project, but if you’re looking at $10,000 or more bill…that’s worth a project. Maybe a war.

Print the thing out, put it on your tablet, whatever, and start investigating. Look at the table of contents, use CTRL-F. You’re looking for terms relevant to your case. In my buddy’s case, that might have been “overnight” or “stay” or…you get the idea. Maybe get a friend to help you. 

Somewhere, that legalese says exactly what your insurance is supposed to cover. That information is your arsenal. 

Mounting an actual battle is a bigger story than we’ve got room for here, but start by putting everything in writing: What’s happened, what their own documentation says they’re obligated to do, what you want — no, what you expect — them to do. Keep emotion out of it, and then send a letter with all of that information to your insurance company. 

“The person who gets the letter has to make the decision ‘Do I ignore this? Or do I bring it to my manager?’” says Jacqueline Fox, a law professor who spent years helping people fight insurance companies.  “And if I was that person and someone [writing a letter] was very calm, that’s the part I’d find alarming. … I would either make sure it’s handled … or do that and give my manager a heads up that there’s a grownup who seems somewhat irritated.”

After the letter, the next steps depend on your insurance company’s response and lots of variables about your situation. 

But to get a sense of the terrain, maybe check out this episode we did about Professor Fox, and a pair of episodes about Laurie Todd, whose professional handle is The Insurance Warrior. The first episode covers her general approach, and the second is about an especially epic battle she fought. 

Her 2018 book: Approved: Win Your Insurance Appeal in 5 Days, is a dynamite instruction manual. 

In the end, my buddy took Route One, and it worked quickly for him. Their doctor knew who to call and what to say, and that was that.

Bonus: A dream come true?

Last year, I ended part one of this Fighting with Insurance series with a dream: What if someone used AI to fight health insurance denials?

This year, a San Francisco tech worker named Holden Karau did just that. Her free tool is in the early stages, but you can test it at her site, Fight Health Insurance. 

Her slogan: “Make your insurance company cry, too.”

I loved the sound of it. So I talked with Holden — who is great — and we will have a new podcast episode about her and her project next Friday! 

Till then,

Dan

P.S. If you don’t already follow the podcast, don’t miss the episode with Holden Karau! You can find us pretty much anywhere you get podcasts.