Communicating with Insurance Companies
Submitting Claims
What to Do About Denied Claims

1. Speak with the person and her doctor about preferred, expected, and possible healthcare needs. Make a list of frequency and type of projected doctor visits, diagnostic tests, treatments, prescriptions, therapies, and possible hospital stays.
2. Review the person’s policies to determine what on the list is covered and by how much, and where there are gaps.  Speak to your insurance representative if the policy language is unclear.
3. If care will be at home, find out what supplies, furniture, nursing, etc. are covered and whether there are conditions for coverage (e.g., a previous hospital stay). Do the same if you plan for care in a nursing home or other institution.
4. Research options for paying for gaps in coverage, deductibles, and co-pays with Medicare C and Medigap policies, and group or other private insurance plans.  Read books, use reputable Internet resources, talk to other caregivers or friends who have experience in the area.  Consult with a financial planner if possible.
5. Purchase what additional coverage you can, given the person’s age, health status, and budget.
6. If you cannot buy new insurance, given your loved one’s health status or finances, find out if she qualifies for Medicaid or other low-income assistance.
7. As your loved one’s prescription needs change, compare Medicare D prescription plans with private insurance plans’ coverage for those drugs. You can switch Medicare drug plans during annual enrollment periods.
8. If unexpected treatments become necessary, call the person’s insurance agent as soon as you can to determine coverage. Hospital admissions and insurance specialists should also know the details of Medicare and Medicaid.  Don’t wait for the bill to tell you that some care wasn’t covered.
9. Keep insurance and medical records in one accessible place.
10. Be prepared financially to cover the expected out-of-pocket expenses for home care, like equipment, dressings, incontinence products, non-prescription medicines, and home care aides.  See Setting Up a Home for a clearer idea of what you’ll need for home care.

Communicating with Insurance Companies

Watch for inconsistencies or vaguely described benefits. Don’t let your insurance company deny coverage for something that has been covered in the past or that you believe should be covered.  Get more information through your State Health Insurance Assistance Program (www.healthassistancepartnership.org/ship-locator/ ), the Medicare Rights Center (www.medicarerights.org), or through another independent source.

When calling the insurance representative, keep dated, written notes of everything that’s said, and get the representative’s name and identification.  Also, keep a record of what anyone else you speak to has to say about the case; for example, doctors and hospital insurance specialists.  Coverage for particular items often falls into gray areas of the policy, so it’s a good idea to document all the interpretations people have given you.

Try to speak to the same insurance representative every time.  This may be more possible with a group insurance policy than with Medicare, but you don’t want to repeat the whole story every time you call if you can avoid it.

The following tips could help the claim process work more smoothly and help you be more organized.

1. If your loved one has more than one insurance policy, determine which should be billed first (primary insurer) and which is intended to cover shortfalls (secondary insurer).  Make sure the person’s healthcare providers and insurance companies are aware of the billing arrangement.
2. If possible, set up an automatic billing process between Medicare and secondary insurance plans.
3. When you receive a bill, immediately file a claim using the forms provided by the policy.  Don’t let bills stack up.
4. Attach copies of the bills, receipts, and supporting documents to the claim.
5. If you have questions about the claim or your coverage, call the insurance company.
6. For questions about the bill, call the care provider.
7. File copies of all bills, receipts, paid and outstanding claims, insurance findings, and explanations of benefits. Good files are your evidence for any future problems or miscommunications in billing and coverage.

1. If the denial is due to a mistake in paperwork, fix it and resubmit the claim.
2. If you’re not sure why it was denied, or you think the claims adjuster was incorrect or misinterpreted coverage, call the insurance company for details.
3. A letter from your loved one’s doctor about why certain procedures were necessary can be helpful.
4. If the claim is repeatedly denied, find out how to dispute a denied claim. Your detailed records will come in handy with this.
5. You can also contact your state insurance regulator or an attorney.