HTSMC: Letters to Blue Cross (and other insurance companies)

In my ideal future world, people will no longer have to deal with profit-hungry insurance companies.  Yes, we’ll still have government bureaucracy but that’s a post for another day.

If you’ve been around long enough, you’ve probably had many dealings with insurance companies over benefits.  I’ve heard horror stories of being denied needed services due to the pre-existing condition clause, which I hope is no longer an issue under the Affordable Care Act. Because I enjoyed company-sponsored plans, my family and I did not have to deal with the pre-existing clause issue. Our most common battle was over covered vs. non-covered services.

Denials can happen if you’re trying to get pre-approval for services or if you obtain a service thinking it was covered only to get a bill for the entire amount.  Over the years, I’ve received many denial of services from insurance companies and I’ve gotten pretty good at fighting back.

In the beginning, I would call or write angry letters that got me nowhere.  Luckily, I was able to find good advice online about how to fight insurance companies.  Since then, I have won all challenges except for one case. That’s because 9 times out of 10, a denied service is actually covered.  Insurance companies just don’t want to pay it.

I will break it down to easy steps and I guarantee you have a chance to win if you do this.

1) Don’t bother calling unless you’re checking to see if it could be a billing code error.

2) Get your hands on your plan’s Explanation of Coverage (EOC) booklet.  This is a thick booklet with detailed explanations about coverage, term definitions, exclusions and more. This is your bible.

3) Go through the EOC and mark all clauses that back up your claim that the service is covered.  In all but one of my cases, I was able to find supporting documentation in the EOC, because as I wrote a few paragraphs ago, insurance companies just don’t want to pay.


Original “Hate Mail” Postcard designed by Mr. Bingo.

4) In a letter, state your case in a calm, professional manner.  When you cite something from the EOC booklet, include the page number in the body of your letter and write “see attachment”. Include a copy of that page with your letter. If you have multiple attachments, refer to each by letter – attachment A, B, C etc.. – and write this letter on the corresponding documentation.

5) Tell them you’re requesting a 2nd review of this matter.

6) End by putting the burden of proof on them. Ex: “If you decide to deny my request, please inform me of the section of my plan description upon which you base your decision to deny my benefits. Please provide me with the names of the persons who have made the decision to deny my payment.”

7) Make copies of letter and supporting documents.

8) Send registered mail with someone signing to receive it. Make sure you’re sending it to the right department. All EOC booklets should include an address where you should send this type of request.

Under the Affordable Care Act, there is a standardized process for appealing claims. Read more here.  I haven’t done this but I believe many of my tips would still apply.

Final Tip: It may take a while to get a response. This can be tricky if you owe money to a doctor or hospital. You can cc: your medical provider’s billing office in your letter or call to let them know that you’re addressing this bill. Writing is always better!

Good luck! Please share your experiences and helpful tips in the comments.

This is one in a series of tips/ideas to help you stay middle-class (HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

A Week In The Life Of Special Needs Parenting

Every week, my spouse and I face a mountain-load of paperwork related to managing a special-needs household.  Below is a sampling.


Spouse handles medical appointment for one kid.

I schedule extra service hours for this Wednesday.


I take a day off from work.

I attend 3-hour parent training seminar required by Regional Center

I pick up dental referral form for one kid

I email back and forth with Service Provider re; insurance denial for one of kid’s services

Spouse and I participate in a therapy session with kid.

I fix a mistake that I made earlier in one of our service provider’s schedule.

Spouse sends in medical supply order and questions to service provider


Spouse brings kid to hospital for check-up.

I research and complete paperwork for a government program.  I hope I get all the necessary forms!

I call Insurance about a denied claim.  Hear a message saying they’re too busy and to call back another day. Search for most recent approval paperwork!

Spouse completes paperwork for IHSS.

I discuss upcoming vacation time with a therapist.

I notice a possible error in schedule for next week and note to bring this up with provider.

I print and save copies of lab results for one kid.


Spouse discusses parent training schedule with consultant

I TRY to submit information online for a government program. I get an error message and contact the agency for help. I would have submitted the old-fashioned way but I cannot find a paper application anywhere on their site.  During this research, I also notice that there are a few additional supporting documentation on their site that were not required in the online application.

I email important documents to kid’s doctor for his signature.

I email insurance about the denied claim.

I call provider about services that is supposed to start for one of my sons in April.


I email Regional Center about services that is supposed to start for one of my sons in April.


We realize that we have 3 special needs related meetings next week.

Add stuff to the To-Do List:

  • Get ready for IEP by reviewing progress reports and decide strategy.
  • Get paperwork ready for foundation meeting.
  • Set a schedule for weekly parent training for both of us
  • Email provider about not being happy with one of the therapists.
  • Find out if one of our recent appointments qualify for a claim with AFLAC.
  • Note to self: Research if we should continue paying for AFLAC insurance.
  • Must follow-up (again) with IHSS
  • Must follow up with kid’s doctor about completing form.

Some weeks are definitely more hectic than others.  It was a fairly slow week at work so I was able to tackle multiple projects.  Many times, I’m just too busy at work to do much else. Unfortunately, it’s not uncommon for it to take-up 2-3 weeks for me to follow-up.

All of the above must be taken care of while we manage a household with two young kids, freelance career and a full-time job! We could not do this without local family support (thanks Mom!)

Better Definitions For Insurance Mumbo Jumbo

If you don’t understand common health insurance term, you may choose the wrong plan for your needs or lose out on benefits. Here’s run-down with definitions taken from a mix of health insurer websites, and Money Under 30.

Premiums – The monthly fee for your insurance. If you belong to an employer-sponsored plan, the premium is likely deducted from each paycheck as pre-tax dollars. If you purchase your own healthinsurance plan, you may have the option to pay your premium annually, quarterly, or monthly.

Co-pays – A fixed amount you pay for a health care service. The amount can vary by the type of service. You may also have a copay when you get a prescription filled.

Co-insurance – Your share of the costs of a health care service. It’s usually figured as a percentage of the total charge for the service.   Typically, the lower a plan’s monthly payments, the more you’ll pay in coinsurance.  Co-insurance is in addition to your deductible. So if your plan has a $100 deductible and 30% co-insurance and you use $1,000 in services, you’ll pay the $100 plus 30% of the remaining $900, up to your out-of-pocket maximum. I don’t think I’ve ever had a plan with co-insurance, hence my confusion.

Deductibles –   Amount you pay for health care services before your health insurance begins to pay. Let’s say your plan’s deductible is $1,500. That means for most services, you’ll pay 100% for most of your medical and pharmacy bills until the amount you pay reaches $1,500.  After that, you share the cost with your plan by paying coinsurance and copays.

To add to the confusion, your insurance often covers preventative health services from the get-go, meaning you don’t have to meet the deductible to get the benefit of lower co-pays. In other words, your insurer will cover most of the bill and you just pay the co-payment.

Out-of-Pocket Maximum – It is the most you will ever have to pay out of your own pocket for health care during the year, not including premiums, but definitely including the deductible AND the copays and coinsurance you will continue to pay after you hit the deductible. If you hit your OOP for the year, your insurance will pick up 100 percent of costs thereafter. The trick is: You are responsible for letting the insurance company know when you meet or exceed the deductible.


Does A Chart Make More Sense?

Finally, my Woman/Man on the Street thoughts and revised definition of the above terms.

Premium – First, why is this called a Premium? That makes it sound like a privilege or reward. No, it’s just money you pay to get insurance in the first place.

Co-pays – In addition to premiums, you also pay co-pays for doctor visits, hospitalization, medication and other medical-related services and supplies.

Co-insurance – In addition to premiums and co-pays, you may also have to pay co-insurance. I don’t know why.

  • Co-pays and Coinsurance seem like the same thing but they’re not!  Does it really matter if you call it a co-pay or co-insurance if you’re paying?

Deductibles – After paying premiums, you pay X-amount in deductibles BEFORE you can even get the benefits of having insurance. That’s right. You pay for insurance premiums which are not cheap, and then you have to keep paying 100% until you reach that magic deductible amount. I’ve been fortunate to have zero deductible plans but if you don’t, you probably have to track of your spending and let the insurance company know that you met the deductible amount.

Out-of-Pocket Maximum – If you’re “lucky” enough to rack up tons of medical bills in one year, you may meet the out-of-pocket maximum. After you hit this magic number, you are not responsible for any co-pays or co-insurance.

  • Deductibles and Out-of-Pocket Maximum seem like the same thing, but they’re not! 

Do you have a headache yet? No wonder we can’t solve world hunger. We’re too busy trying to figure out health insurance. If you can come up with better definitions, please do so in the comments.

HTSMC: Know Your OOP

This is one in a series of tips/ideas to how to stay in the middle-class (or HTSMC).  Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.

Don’t be a fool…

know Your OOP.

It Means “Out of Pocket Maximum

And it’s the most you can spend

on healthcare each year.

What’s the Max, you ask?

Depends on your plan

$1,500, $3,000, you gotta

read your Benefits booklet!

Etch That Amount

In Your Brain…Now

The Insurers Don’t Help

It’s Up To You

To Keep Track.

So my advice is:

Don’t pay more thant you should,

Know your OOP!!!

Okay, my poetry/rap SUCKS! I just thought it would be helpful to break up the information into little chunks. Not many people know about this rule but I cannot stress enough how important it is to understand this term and take full advantage of it.

The dictionary definition of Out-of-Pocket maximum is: The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits. – From

The first step is to read your benefits booklet.  In addition to knowing your out-of-pocket maximum per year, you need to know what is included or excluded.  For example, with my HMO, prescriptions do NOT count toward this out-of-pocket maximum.

The second step is to keep track of your family and individual spending.  However even if you’re great about tracking these expenses, your amount still may not match up with the insurance company since they don’t count it until after the bill is processed, which can take weeks or months. To add to the frustration about this process, it can take a long time for your doctor or hospital to bill the insurance company.

Let’s say your out-of-pocket maximum is $1,500 per calendar year.  You’ve spent $1,000 in qualifying expenses when you’re hit with a large hospital bill. This bill is $800, which will make you go over the OOP amount.  When you get the bill, however, the insurer hasn’t processed that bill yet. That means you have to pay the bill and then figure how to get reimbursed.

Last year, I was successful in proving that my family met the out-of-pocket maximum.  I tried tracking our medical spending in Excel but my totals never quite matched the insurance company records. Not a big surprise. Luckily, I discover a better option.  Most insurance companies have a Claims section on their website.  This should show you all claims for everyone in your plan.  In my case, it was easy to find a list of claims and filter out those that were “pending” or “denied”. Then I export the “processed claims” data into an excel spreadsheet and went through it line-by-line to make sure that these counted toward the OOP maximum.  Then I used this information to back up my email to the insurance company.

Even though I used the company’s own documentation, their customer service representative wrote in an email that their records did not match mine.  I wasn’t going to give up.  I continued monitoring the paper trail (or online trail) of claims information and planned to contact them again.  However, before I had a chance to re-submit, I received a letter from the insurance company stating that my family had met the out-of-pocket maximum effective [date, year].  It is very important to note that the insurance company states it is the client’s responsibility to contact them when they meet their out-of-pocket maximum.  I can only assume that my email was forwarded to another person who authorized the payment.

With this letter in hand at every medical appointment, we were no longer responsible for co-pays that year. Your medical provider can also call the insurance company to verify this information but it’s easier to just show the letter.

By knowing my out-of-pocket maximum, I was able to save hundreds that year.  If you had good or bad experiences with proving you met your OOP, please share in the comments.

Final tips: Be very persistent. Do as much as you can IN WRITING. Make copies.  

News: Middle-class Struggle To Pay For Health Care Despite Insurance

This is a must-read for anyone who has insurance through their job.  According to USA Today, “..nearly half of middle-class workers skipped health care services or fell into financial hardship because of health expenses.”  Are you one of these people?

four in 10 working-age adults skipped some kind of care because of the cost, and other surveys have found much the same. The portion of workers with annual deductibles — what consumers must pay before insurance kicks in — rose from 55% eight years ago to 80% today.

Four in 10 working-age adults skipped some kind of care because of the cost, and other surveys have found much the same. The portion of workers with annual deductibles — what consumers must pay before insurance kicks in — rose from 55% eight years ago to 80% today.