Nobody Cares About Your Insurance Benefits But YOU

Don’t think for an instant that insurance companies care about saving you money on your medical expenses. It’s your job to make sure they cover everything your plan provides, and that the money actually gets where it’s supposed to go. If you don’t, you could pay hundreds or thousands of dollars too much out of your pocket.

My daughter got braces on her teeth earlier in the year. Our insurance provides orthodontic coverage of 50%, with a lifetime maximum benefit of $2500. Each month the orthodontist sends the insurance company a bill for $229 and in return the insurance company sends a check for $114.50, or 50% of the bill, back to the orthodontist. As part of the process I also receive an explanation of benefits detailing the transaction as well as showing how much of the lifetime benefit had been paid out.

Cross checking the amount listed on my latest explanation of benefits statements to the information from the orthodontist, I noticed a discrepancy. Digging deeper, I found that the insurance company listed a payment of $114.50 every month since my daughter got her braces put on, but the orthodontist did not record a payment received in September.

I asked the orthodontist office to look into the missing $114.50 payment.

After some investigation, the orthodontist’s office reported that the insurance company was sending them a fresh check for September’s benefit payment. Somewhere the check was misplaced and was never cashed. The insurance company agreed to send a new check, and the payment was posted to my account in two days.

While I was happy to have the situation resolved quickly, it exemplified just how little attention insurance companies and medical providers pay to your benefit money.

The insurance company had a check outstanding for several months. One would their accounts wouldn’t balance out right, and they’d have some mechanism to notice this fact. One might think they might inquire as to why this check hadn’t been cashed. Or, one might resign themselves to the fact that in the whole grand scheme of things $114.50 wasn’t even a blip on their radar.

The orthodontist didn’t receive a payment from the insurance company. One might think that would be flagged in their system, and they would call the insurance company to inquire why.

Neither of these things happened. It’s up to you and I to ensure the insurance company pays the benefits spelled out by your plan, AND to ensure those funds are properly received and recorded by the medical providers. Each time you have to deal with a medical service and your insurance company, you must do these things:

  • Check Your Explanation Of Benefits (EOB) : Make sure you understand what every charge is on your EOB. There may be several charges for a single visit. If you do not understand every charge, call and have it explained to you.
  • Talk to Your Medical Provider : Each charge on your EOB will have an enumerated code. If a service is coded incorrectly, it may not be covered by your insurance company. Don’t be afraid to question how they coded a procedure. If you can convince them to change it, they will re-submit it to your insurance company.
  • Watch Your Bill : Your explanation of benefits will state the payment being sent to your medical provider. Keep your EOB and match that amount to your next statement from your provider to ensure the payment is received and applied to your account.

Insurance is supposed to help make medical expenses affordable. But neither your insurance company nor your medical provider is as interested in whether your insurance is applied correctly as YOU. Mistakes happen, which is why you MUST follow these steps to make sure you get every cent of benefit you deserve from your insurance policy.

How about you, EOD Nation, have you found a mistake when dealing with your medical insurance company? Were you able to get it corrected?

About Travis

4 Responses to “Nobody Cares About Your Insurance Benefits But YOU”

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  1. Shay says:

    Almost every year, no EVERY year, I have to call our insurance company and get my children’s preventative care office visit reprocessed. Somehow the insurance company doesn’t know their own rules. It’s a $35 copay for the office visit, but every year they don’t apply the copay and apply the whole office visit to my deductible. When I get it reprocessed (for three children), it saves me $90 a kid!!!! It’s so frustrating to have to do this year in and year out, but it’s worth it to save $270!

  2. Sassy Mamaw says:

    I had a situation a few years ago, where my insurance wasn’t covering my lab work. It turned out that even though the Dr was covered by my insurance, his lab wasn’t. Each time I needed lab work, I had to go to an outside lab. It took months to figure out the issue!

  3. I have been incredibly fortunate not to have had any issues so far. I do check my statements though to ensure that they’re not claiming they’re doing something they didn’t perform. To date I’ve been good so hopefully I stay vigilant and don’t let my guard down. Thanks for the great reminder!!!

  4. kayjay71 says:

    Going to play devils advocate here….but yes the insurance company does follow up with providers on checks that remain uncashed…however there is a waiting period that has to happen before the follow up happens. One would think that the provider here would have questioned getting payment the month prior and months after and followed up themselves….however dental providers are notorious for being difficult to work with as far as payments and insurance are concerned so I’m not shocked they just opted to bill you instead of calling to get the payment reissued themselves.

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