Health Ins Claims: When Your CSR Isn’t Helping, Should You Take It Straight To The Top?

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Jul 16, 2021

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The process of getting a simple health insurance claim paid can be very frustrating and often leads to bad faith insurance claims. When nobody seems to know what’s going on, you’ve explained your situation over and over again and your customer service representative (CSR) just isn’t helping, should you take your concerns straight to the top of insurance companies such as Aetna, Cigna, Anthem Blue Cross, WellPoint, Humana or Kaiser Permanente?

Frustrating claims processes

It probably wouldn’t be a stretch to say that nearly everyone has had an issue with getting a health insurance claim paid at one time or another. In fact, according to a recent J.D. Power & Associates survey, 9% of insureds had to make three or more calls to resolve their claim issues, nearly 40% said they’ve had to repeat the same information over and over again to different CSRs and approximately 25% said that they’d never received return phone calls from insurers who promised to call back. Those who simply can’t get their claim paid through normal channels often elevate the issue by bringing it straight to the top.

According to an article in the Wall Street Journal, many people have sent personal letters to the top executives at some of the largest health insurers in the nation, pleading for them to intervene. Here’s how the WSJ says the top brass of these companies handle problems:

  • Aetna: Chief Executive Ron Williams says he does “read every one personally,” and “when I see a letter that is particularly concerning for whatever reason…I will ask to see the response to really understand the issue.”
  • Cigna: The insurer says it refers such communications to a “specially trained service team that is staffed by people who are experts in resolving complex issues.”
  • WellPoint: The insurer punted on the question and told the WSJ, “We want people to know we are very responsive to our members.”
  • Humana: Chief Executive, Mike McCallister, says that he “makes an effort” to read emails sent to him by members.

While it’s interesting to hear how these insurers’ higher-ups deal with the issues, what can you really do to resolve your problem?

Tips to resolving claims issues

The WSJ article provided the following tips to resolving claims issues before needing to take it to the top:

  • Exhaust your remedies. Make sure you exhaust all CSR remedies beforehand or you’re likely to find yourself back at square one.
  • Document everything. Document who you spoke with, when you spoke with them and what was supposed to happen.
  • Stay on the phone. Kaiser Permanente’s Senior Vice President of Customer Service told the WSJ that customers should “Stay on the phone until [they] get the answer that [they] need,” including requesting to speak with a supervisor when necessary.
  • Check with your HR department. Many employers have self-insured plans, so contacting your Human Resources department may be a good place to start in those situations.
  • Prepare your ‘case. Prepare your case as if you knew you had to appeal the insurer’s decision. That way, you’ll have the names of doctors, the dates of procedures – and everything else – at your fingertips and ready for further action if warranted.
  • Kill them with kindness. Nasty letters often get placed at the bottom of the pile. Customer service representatives say that those customers who express their frustration in a nonthreatening tone tend to get better results.

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