Sam’s Story The True Story of How One Man Overcame Death And His Health Insurance Company
Sam heard the garage door open, so he knew his wife and two young children had returned from grocery shopping. Suddenly, the car horn starting blaring, a designated emergency signal for assistance. Sam ran out with his baseball bat and was confronted by a drunken, knife- wielding man trying to get into the car.
Fearing for his family, Sam fought with the man and was able to subdue him until the police arrived. He was repeatedly stabbed in the neck and seriously injured. He saw his life pass before him.
He was rushed to the small rural hospital where he was an employee. The seriousness of his injuries required a trauma center, and he was flown to the only major city in the state, 150 miles away. This city had three hospitals, and only one was the designated trauma center. It was also the only hospital his insurance did not have a contract with.
Sam was released from the hospital six days later post surgery.
Four weeks into his recovery, he received two letters: one from his insurance company stating he was being denied coverage because the hospital was out of network and one from the hospital stating he owed $40,000. Once again, he saw his life pass before his eyes.
At this point, Sam called me. My first step was to read the insurance policy. I was looking for the following: the deductible, coinsurance, co pay, out of pocket limit, out of network and emergency services definitions and appeals process. I was able to determine he had a $200.00 a day co pay for a hospital stay with a limit of $800.00. Emergency services were covered whether in or out of network and transport to a higher-level facility for treatment, was paid in full.
The next step was to get an itemized bill from the hospital. I was looking for incorrect medical codes and charges, double billing, incorrect medications and medical procedures charged. I did find multiple inconsistencies including charges for out patient services while he was inpatient!
Good communication is the key to success in any billing issues. To avoid any collections, I asked the hospital and providers to put the bills on hold until the issues with the insurance were resolved. By doing this, the facility knew something was being done to resolve the bill
When dealing with an insurance company, communicating with patience and calm works best as well as writing down the name of the person you are speaking with and details of the conversation. The first stop is always the customer service representative. Companies use them as the front line to consumers in hopes of resolving initial issues and deflecting any potential problems.
In Sam’s case, I initiated the process by reviewing every denial and requesting further details. My goal was to get the bills resubmitted for further review by an in house pre appeals department. I was successful in getting all the claims to be resubmitted.
I know not to be lulled into thinking the problem is going to fix itself because of one phone conversation. I call back regularly and frequently to confirm the claims have been resubmitted. I also know that speaking with different people, I get different answers and can inadvertently elicit insider information. One phone call, yielded the specific reviewer’s name, phone number that is classified secret information.
Multiple conversations with the reviewer resulted in the bill being paid in full by the insurer. The determination was based on the fact there was no other trauma center, and as it turned out in these situations the trauma hospital and insurance had a contract for services.
Sam’s case never had to go to appeals. His final bill was the $800.00 co pays for the hospital admission per his policy.
The lesson from this case is this: If your insurance policy specifies treatment you are entitled to, then you must be vigilant to ensure that your company actually does pay for the services. In addition, understand that it may take time and persistent effort to receive the coverage your policy provides. Sam’s positive outcome required two months of regular phone calls to both the hospital and the insurance company for continued clarification. Progress was sometimes frustratingly slow, but once they understood that we knew what we were talking about—and that we weren’t going to give up and go away—our success was inevitable.