Navigating Insurance Claims

Navigating insurance claims

Insurance is an intangible product you might need a few times a year. But in an instance, you can be left with a substantial medical bill, and it seems like you’re the only person who can understand the fear and uncertainty. I’ve been given great insight by working in the insurance industry for the last year. I grew up with a father in the military, and as his dependent, we had health insurance through Tricare.

I lost my medical insurance after graduating from college in 2020, and the world was in the middle of a pandemic. This new reality I was in, quickly made me realize the necessity of insurance and the difference to my well-being and future finances it would make.

When I started working at Benefit Management and Brokerage, I became an administrative assistant and claims specialist during our busiest time of year. October through January is our company’s most prolific time, but there can be many delays and frustrations with carriers. Claims departments often become overwhelmed in attempting to compensate for the past year. Therefore, I want to advise the best ways to navigate insurance claims.


Claims usually start with an invoice or explanation of benefits showing the insurance didn’t pay as much as expected or didn’t pay. Billing offices send out invoices regardless of the claim process, and clients are worried they will have to pay out of pocket.

Benefit Managment’s objective is to ensure a claim is processed and paid within the confines of a client’s medical plan. As the administrative assistant I gather claim forms and supporting documentation from the beginning to send directly to the carrier. Our team contacts the carrier or provider’s offices on behalf of our clients, which saves our clients time and money. In addition, with a claim in good standing, it will take less time to process.

Our clients work with us to decide to file a claim, such as a short or long-term disability claim. The stress related to the inability to work is scary, so these are often my most essential claims to complete. I monitor any status updates and inform our clients of any possible delays or requests. However, most claims are between the provider’s office and the claims department within the insurance company. There can be miscommunication between these two, and that’s where our team at Benefit Mangement comes in.

How are claims paid?

We often get asked by clients how an insurance carrier will pay a claim. The medical plan ultimately determines this, but several factors go into a claim: deductibles, copays, and coinsurance.

Deductibles are a member’s out-of-pocket amount within a calendar year before their policy starts paying. Specialists and facility visits (ER, Urgent care, inpatient, and outpatient) carry copays. After a deductible is met, coinsurance is the amount you pay for covered services. For example, if you pay 20% in coinsurance, your medical plan will pay the rest 80%.

All three of these payments add up to an annual out-of-pocket max. The great thing about a medical plan is there is a limit to how much you will pay out of pocket. Usually, most clients won’t reach their out-of-pocket max in a given year, but there might be issues along the way.

What are the common issues with claims?

Claims often get delayed to clerical errors from the billing office and must be refiled with the insurance. We work on a variety of claims leading to different outcomes. However, a few situations that will lead a carrier to deny payment.

In-network vs. out-of-network:

This is the most crucial part of understanding insurance claims. Medical plans are within a specific network affiliating with providers, facilities, and pharmacies. An in-network provider or facility will have a less out-of- pocket cost for you but still might be subject to deductibles and copays. Out-of-network claims will always cost more because the provider or facility set their prices.

For example, I used an out-of-network dentist and had to pay $300 out of pocket. My dentist claimed to be a Delta Dental provider, but he was out of network with my plan. So, I switched dentists for my next cleaning, but I wish I had known beforehand. Particular places to be careful are emergency room visits and laboratories.

Emergency room visits can have high costs because of not only copays but provider costs as well. For example, you may go to an in-network ER, but you receive care from an out-of- network provider. In this instance, you would be responsible for a copay in addition to provider fees. As your broker’s office, we can help you find the best in-network providers and facilities to avoid these sneaky bills.

Preauthorization’s, Denials, and Exclusions:

Many medical procedures require preauthorization’s beforehand, and clients want to ensure their insurance will cover services. When applicable, I mediate communication with providers to obtain medical records or supporting documentation for the carrier to review. Denials are seen regularly with pharmacy claims.

Several factors go into pharmacy insurance denials, including preauthorization’s, quantity limitations, and drug exclusions. For example, carriers often require preauthorization’s before a prescription is covered based on the price or interaction risk such as taking an opioid(hydrocodone) with a benzodiazepine). Therefore, we can advise your provider to submit preauthorization’s, appeal denials, or try alternatives covered by your insurance plan.

Coordination of benefits:

Every year, you should update your Coordination of benefits with your insurance. This notifies the insurance carrier if you have additional insurance
coverage, preventing two or more insurance plans to pay for the same claim.

In addition, it keeps premium costs down and informs providers which insurance company to bill as primary or secondary. The Coordination of benefits is the backbone of insurance coverage and, therefore, the foundation of claims. As with claims, we will assist clients in updating information with their insurance carrier.

How BMB can help you with claims?

Handling claims for a vital operation or medication can be daunting. Our team is here to help you with any issues with your insurance. Please get in touch with us at 985-649-0350.



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