10 secrets every health insurance company knows

Calling your health-insurance provider is right up on the Most Dreaded List with getting a colonoscopy. But there will come a day when you can’t avoid calling that toll-free number, pushing 2 for English, 4 for Claims, keying in your 47-digit Group ID number, having your 47-digit Group ID number electronically read back to you, and then (finally!) being told your wait time is 50 minutes. But there is a better way. We actually got through to these insurance people (and other experts) and asked how to make this whole process more efficient. Here’s what they told us:

1. Don’t call on Monday.

This is like trying to get through to the Heavenly Ham store the week before Easter. You’ll be on hold forever, along with everyone else who had questions arise over the weekend, says Elisabeth Schuler Russell, founder and president of Patient Navigator, LLC. Try Wednesdays, Thursdays, or early Friday before people start wrapping up for the weekend, she says.

2. Be prepared before you call.

Have your insurance card and the document in question (medical bill or insurance company statement) handy. If you’re calling to see if an upcoming treatment will be covered, have the diagnostic and procedural codes from your doctor. Being prepared also means having something to do while on hold. Multi-tasking will ease your stress.

3. Sweet-talk ’em.

Even though your inclination may be to curse and scream when someone finally picks up the phone, remember that’s a human being and this isn’t her fault. “Be collaborative and never throw gasoline on a fire,” says registered nurse and patient advocate Teri Dreher, CEO of North Shore Patient Advocates in Chicago. “Be exceedingly polite; say ‘thank you.’ Use her name, and show the impact their assistance had if you can.” Being nice makes it more likely they’ll go the extra yard for you.

4. Understand your plan.

Most people read the “101” version of their benefits, typically a pamphlet or PDF summarizing coverage. But if you’re contesting something, you’ll want to have the “201” version, says Russell. This is called the “evidence of coverage” or “certificate of insurance,” and it’s typically much heftier — sometimes up to 200 pages. It may be mailed to your home or posted online, but sometimes you have to request it. Then you can ask the rep, “Could you please point me to the document you’re referencing?” says Dianne Savastano, founder of Massachusetts-based Healthassist, which helps patients navigate the insurance system.

5. Record everything.

The automated voice that says, “this call may be monitored” is good advice for you, too. Note the date and time, the name of whomever you spoke with, and any details about what they said, so you have a documented version of the conversation just like the insurance company does. In fact, you can record the conversation as well.

6. Insist they translate jargon.

Insurance-world jargon can be intimidating, so don’t be embarrassed to say to a rep, “Help me understand what that means,” says Scott Josephs, MD, national medical director for Cigna Health Insurance. Here are some common terms and their meaning (find more at Healthcare.gov/glossary):

7. Ask to speak with a nurse.

That’s right, many case managers at insurance companies are registered nurses, explains Dreher, and they’re usually more knowledgeable and sometimes even more sympathetic to your cause. So if you need assistance with a medical question and your customer service rep isn’t being helpful, ask politely for an RN.

8. Follow up.

If the insurance company promises to get back to you by a certain date, put a reminder in your calendar to follow up immediately after you hang up, says Savastano.

9-Always get it in writing.

If the insurance company is making an exception to coverage rules, get that agreement in writing. Dreher had a client in Illinois who needed a complicated surgery that no in-network, local provider could perform. The most experienced surgeon was out-of-network in California. The patient’s insurance company verbally agreed to cover the procedure, but afterward, he received a bill that didn’t line up with what had been promised. Fortunately, he had documented every detail, and Dreher helped him file an appeal.

10. Don’t pay until these numbers match.

After a medical appointment or procedure, you’ll receive an “explanation of benefits” from your insurance provider as well as a bill from your doctor. Both documents will specify how much money you owe the doctor. In a perfect world, these two numbers should match, says Russell. If they do, pay that amount. If there’s a big discrepancy, call the doctor’s office to make sure it billed the insurance company correctly. Just because $ 600 may be the average rate for that procedure, a doctor could charge $ 1,000 simply because she did it at a different hospital.

While insurance companies generally won’t budge on discrepancies like this, hospitals and doctors might, says Dreher. Ask to speak with a medical adviser at the hospital or doctor’s office and explain any financial stress you’re under. But instead of asking for the entire bill to be waived, offer to pay a sizeable portion (say 50% to 60%). At the very least, you could get a more reasonable payment plan, says Savastano.