My personal adventures in health insurance verification…

– By Kristen Garron, RD, LDN, CDE

Have there been any documented deaths from waiting too long on hold with an insurance company?

I may have come close a few times. The hold times can be anywhere from a lucky few minutes to my all-time record of 37 minutes. Speaking of, I am currently in minute 23 as I type.

Part of my job as a diabetes educator for group diabetes self-management education classes is to check my patient’s insurance coverage for our program. I obtain each patient’s name, date of birth, insurance plan, and member ID number. When I call each plan, I have to provide the same information each time.

I’d like to think I have gotten pretty good at these calls since I have had to make so many; however, my tip to you for any future call you may make to your insurance company is to be ready to say “Are you sure?”.

Let me give you an example:

One morning I called an insurance company and gave my normal spiel. I provided the code the insurance representative needs to look up the coverage for the diabetes program and did what I now do best, waited on hold. When the representative came back from her cyber world of hidden insurance information, she stated that the patient’s coverage for the program was as follows: “The code is valid and billable, no referral is needed, no prior-authorization is needed, the plan will cover the cost of the classes at 100% but there will be a $100 co-pay for each date of service”. (Note: our program is four classes total, hence the co-pays alone would be $400)

After she was finished, I said with the most perplexed face you can imagine (enter the title of the article) “Are you sure?” I continued to say that I have never heard of that coverage scenario before. What she didn’t know is that I got a tip from a very friendly and very intelligent rep from the same company during a prior call. The rep told me that the code I asked for is considered a “downstairs benefit” but I can’t tell anyone that term because it is only internal company lingo and they are not supposed to use it with patients/providers. He then told me that the code I needed is then located in a specific tab downstairs (in the dark cellar apparently, the one everyone is afraid of, think Home Alone Kevin McAllister scene).

So, back to my current call, I kindly asked the rep to please check the downstairs benefit under the specific tab. She laughed and said, “Oh that is a good idea! Wait, how did you know to ask for that? Please hold I will be right back.”

When she returned she apologized because the patient’s coverage for diabetes self-management education was now, per the benefits in the spot I asked her to check, covered at 100% with no co-pays. I was relieved and happy that the advice I was given by the very kind rep helped to clarify this patient’s coverage but at the same time it made me so mad.

– How many other calls for different insurance companies has this happened to me and other providers/patients that were checking benefits and coverage for?
– How many people with diabetes have not attended such an important program like diabetes education classes because a rep didn’t know where to look within their plan?
– How many patients were told wrong information due to a lack of knowledge on where to find the coverage correctly within the patient’s plan?
– How many times has someone waited on hold only to get the wrong answer?

If you felt immediately frustrated reading any or all of those questions then you get it. Beyond frustrating to think you have to ask such a silly question like “Are you sure?”. To be fair, not every scenario or call to an insurance company will be like the calls I make. However, the moral of this story is, like many things in life, if it doesn’t feel right… it probably isn’t.

Ask questions. Keep asking questions.

Ask specific questions that dig and dig deeper until it feels right. If you feel like you’re in a dead end in the conversation you’re in then kindly ask for a manager, don’t waste time like I have before settling for the wrong answer due to complete frustration.

Instead, hang in there.

Get someone else on the phone and keep plugging away. It is your insurance plan and you deserve to get accurate information, especially after the record-breaking hold times. My best advice to you if you are calling about diabetes related coverage is to have as much information in front of you as possible.

Here are my tips:

  • Have your insurance card in front of you
  • Know where the service will be rendered (ie physicians office or facility)
  • Know the procedure code a.k.a. the “CPT” code
  • A diagnosis code is usually helpful as well, if available
  • Ask if diabetes education a covered benefit on your plan
  • Ask how many visits or hours are authorized per year
  • Know or ask if your plan runs on a calendar or contract year
  • Ask if a referral is needed
  • Ask if a prior-authorization is needed
  • Ask if there is a co-pay, deductible, and/or co-insurance
  • Ask what the deductible accumulations are
  • Ask for the representative’s name and a reference number

Hopefully those tips will help you be more prepared for your next call. Now please excuse me, I should be getting off hold at any moment now. Yeah, you’re right, I’m not sure.

Note:  Kristen Garron is Director of Group Education at Integrated Diabetes Services.  She can be reached at Kristen@integrateddiabetes.com