Navigating the Health Claim Maze


The second half of getting sick is fussing with the health insurance claims process. I have some tips to pass-on from my own health claims experiences that might help you navigate this maze. Since I also sell health insurance, my understanding of the process and structure gives me an added perspective. This is not a rant on health insurance business or healthcare - just some techniques that can be helpful.

I am way too experienced in running the Health Claim Maze. Unfortunately, I lost my older brother to cancer last year and as his friend, and later executor, had the task of helping on the insurance issues.

First the Good News

I have always gotten the right answer eventually from every health insurance company on every health claim I have dealt with. Each and every insurance company honored their insurance policy and correctly paid what was due (or had a valid reason to decline a claim). Most claims were handled correctly and timely without any intervention.

This included the Kansas Health Insurance Association (the Kansas health insurance risk pool) which paid over $500,000 for my brother's lymphoma treatments over his two year illness. It gave him access to any treatments that were appropriate. The final cost to him, in addition to his monthly premium, was his deductible and cost sharing of $3000 for each of the two years ($6000 total).

The core value of any health insurance plan is offsetting the huge financial risk of a major illness or injury and getting you access to the treatment you need.

Choosing the Right Insurance Company

Claims service matters. Unfortunately, most folks select insurance companies based on price and not value. An important value to consider is the ease of getting help if you have a claim.

Look for an insurance company that has kept their claims call center in the United States. Nothing will make the claims process more frustrating than trying to get help on a complex health claim over a bad phone connection with someone who is talking a different version of English. Avoid any insurance company that has chosen the cheap off-shore claims helpline strategy.

Second, ask around about the claims service reputation of an insurance company. This is a good question for your insurance agent. Some insurance companies focus on making the claims process easier while others only offer only adequate service. It is worth paying more and getting the quality service.

Organization Matters

Setup a filing system to keep all claim benefit paperwork. Since the annual insurance deductible follows the calendar year, it is helpful to sort any claims "Explanation of Benefits" by the year the healthcare service was rendered. At the very least, have a box or file to toss any health insurance paperwork - keep it all. You will need this paper trail if a major health claim problem erupts.

If you are dealing with a major illness with a high volume of claims documents you will need a more advanced filing concept. For my brother, I had three files for each year: 1. Paid Claims; 2. Claims in Process; 3. Claims being appealed. I also stapled any unpaid healthcare provider invoice or appeal letter with the claims documents. Within these files, all claims paperwork was sorted by date of service. With pounds of claim's documents generated by my brother's illness, organization of the paperwork was very important.

The Contract / Sales Booklet

Always keep in your file the actual health insurance contract and the detailed sales booklet. The sales booklet is much more accessible and a good starting point to understanding your benefits. I purposely send the detailed booklet to each of my clients when they apply for insurance. The contract is what the health insurance company is obligated to do in exchange for your premiums and is the final word on any dispute.

Troubleshooting the Maze

Most health insurance claims are automatically (particularly if you are "in network" with your healthcare providers) and correctly handled. With any organization, even if well intended and well run (I count most health insurance companies in this category), balls are still going to get dropped and mistakes will happen. Always treat the claims representatives politely (my wife's very wise advice) and enlist them as allies.

Here are three primary claims problems with troubleshooting techniques that I have used:

Problem #1: Claim Denied

Health claims are often denied for minor technical reasons. Don't panic. You have work to do.

First Action: Call the Insurance Company's claims office and ask for an explanation. Why was the claim not paid? Often it is a simple problem that can be quickly corrected.

For example: a client that had a hospitalization ($45,000 three day hospital visit due to a heart rhythm problem), but had the claim initially declined by the insurance company. A phone call to the insurance company revealed they needed a detailed bill to process the claim but the hospital had only sent a summary bill. This was quickly resolved with a second call to the hospital. A payment for the claim (less policy deductible) was quickly sent.

Second Action: Appeal the Claim. You will see on any "Explanation of Benefits" a procedure to appeal any claim that has been denied. Follow this path (normally a mailed letter). Keep a copy of everything. You need to appeal within a limited time period. I made it a policy with my brother's claims to appeal the same day I received any Explanation of Benefits that did not pay the claim. Always send an appeal by certified mail to establish the date the appeal was made and who it was sent to. An appeal forces a higher level of assessment and typically shifts the claim to a special claims appeal review department.

Third Action: Follow up the appeal with a phone call. Normally, you will get an appeal response by mail within a specific time frame outlined in the appeals process. If you don't receive a timely response or a response that you don't understand, call the claims appeal office and ask for help. Request a supervisor if you don't get an adequate answer.

Fourth Action: Ask for a copy of the contract clause that impacts the claims outcome and reread it. Have the claims representative or the supervisor explain the contract language and why the claim is ineligible for payment. You will eventually get the right answer (I always have). If the right answer is a denial, you are owned an explanation you understand.

Problem #2: Past Due Notice from Health care Provider.

This is a warning flag - something has gone astray in the claims communication or processing and you need to figure it out. Intervention will be needed.

First Action: Confirm with the healthcare provider that the claim was properly filed. Several times, I have found that the provider never got the policy information and was unable to file a claim.

Example: Both times that my brother was taken to the hospital, the ambulance service was never given any insurance policy information. The late notices alerted me to call them and provide what they need to file the claim.

Second Action: Call the insurance claims call center and confirm that they received the claim. Ask for an explanation on why claim payment has been delayed. Discuss when the claim payment will be handled.

Third Action: Repeat if necessary. If not resolved after calling the provider and health insurance claim office a second time, request the insurance company to contact the healthcare provider and resolve the communication issue directly. If this is refused, see: "Fourth Action."

Fourth Action: The "Poor Man's Conference Call" - my favorite technique to deal with communication barriers between healthcare providers and claims processors. Get access to two difference phone lines (I normal use a land line and my cell phone) and call both of them at the same time with a phone at each ear. Force them to dialogue with you as the conduit until the problem is resolved or until they accept your request to discuss the problem directly without you.

The "Poor Man's Conference Call" has worked both times I had to use it. Reserve it for your stubborn communication problems when you need a "nuclear option" to force direct contact to resolve a claim problem. Because of HIPAA rules and legal risks, it is normal for healthcare providers and insurance claims processors to be reluctant to discuss any claims issues directly. Health care is a crazy world with privacy, legal barriers, office procedures and multiple layers of processors that limit cooperation and foster communication impediments.

Problem #3: Out-of-Network

The best way to avoid claims paid at the much lower "Out-of-Network" rate is to make an honest attempt to use "In-Network" vendors. If you choose to use providers that are not on the preferred list, you will pay more out-of-pocket and often have to meet a higher deductible.

Below are situations in which you are forced to use providers outside of the prefer ranks:

First Situation: Emergency Treatment. The health insurance contracts that I am familiar with and sell make an exception for any network issues if you are unable to choose a preferred provider due to bonified medical emergency. Your claim will likely be processed initially based on the "Out-of-Network" rates and then you will need to appeal for claim payment based on the emergency treatment exception and request adjustment to an "In-Network" settlement.

Second Situation: No Ability to Select an In-Network Provider. I have appealed and been successful based on the argument that there was no opportunity to select a preferred provider.

Example: My brother was transported by an ambulance service that was summoned by calling 9-1-1. He had no control over which ambulance was dispatched. The ambulance service was not a preferred provider and the initial claim was figured based on "Out-of-Network" rates which left a substantial balance. After an appeal, this balance was paid by the insurance company.

Another example: You select an "In-network" facility but are assigned an "out-of-network" doctor or provider. My brother's pathology sample was sent to a lab that was not a preferred provider. He had no control of the transaction and no ability to select who got his lab work. I again was successful on appeal.

Third Situation: No network provider available. Any health insurance contract that I am familiar with has an exception for any network issues if no preferred provider is reasonably available. You may have a basis to appeal if you can show that no provider on the network will take you or that none of the preferred providers are within a reasonable travel range.

Example: My brother's doctor that specialized in infections was not a preferred provider. All of the claims from this provider were initially process as "Out-of-Network." I was able to prove that no "Infections Doctor" that was on the preferred provider list was available to treat my brother within 30 miles. An appeal, based on network provider availability, was then successful and the claim adjusted.


While most health insurance claims are processed correctly, you still need to be prepared for the few that aren't. Always follow-up with phone calls, ask for help and appeal an unfavorable outcome, if necessary. Be polite and enlist the claims representatives to be your allies. Remember, you deserve explanations that you can understand and help resolving any claims processing problems. I hope my organizational and troubleshooting tips are helpful.