Ask the Insurance Operations Guy!

I currently work for a very large insurance company (UHC), and have a (in retrospect) stupefying background in how things really work in Claims, Underwriting, Sales, Service, and darn near any other section of an Insurance Operations area (appeals, Medical Necessity, etc.).

I’m here to answer any questions you may have about how things work in an insurance company, and more particularly WHY they work in a certain way. I have a solid background in small-group, mid-market, and the jumbo accounts.

Potential Questions:

[li]I got another flipping letter today asking me about an accident…there was no accident! Why do I keep getting this letter?[/li][li]Why is my insurance company asking if I have other insurance?[/li][li]Why was my appeal declined? It makes perfect sense to me![/li][/ol]

I will state ahead of time that I am not a clinician, but I’ll take a stab at answering any question you can think up.



What do you mean by ‘clinician’? Is that a staff doctor who reads charts and X-rays as part of the rating process?

Did you actually have to sell them your soul, or do you just put it up on a shelf when you come in every day?

Sorry…clarity is useful!

By “Clinician”, I’m referring to the fact that I won’t be able to offer a whole lot of insight if a SDMB member were to ask me “Why was I declined for insurance” -with “X” set of medical conditions.

Insurance companies are large hire-ers of clinicians (MDs, DOs, RNs, PsyDs, etc.). We keep a large amount of them on staff in order to offer guidance in program development, appellate work, and for pre-certification.


Actually, when you start at UHC, they give you a very nice pewter soul-holder. You pin it to your cubicle wall, and neatly place any spiritual pieces you may have in the soul-holder at the start of your shift.

We also have a larger soul-holder with spiky bits on it. That’s for the souls of the embittered knee-jerk anti-insurnace-company people. We often go on night-time raids where we extract the souls from the innocent.


Why, when I call, with my plan number, my employer, my plan type, and ask “Is an appointment with a doctor, Dr. Smith at 123 Main St., for a routine physical covered?” can they never tell me?

(Feel free to substitute “dentist,” “specialist,” “internist,” “surgeon,” “gyn” and any other procedure in for the treatment as well.)

Instead, I get asked “Is she in our network?” (Shouldn’t they know? It’s their network, surely their information is more up to date than mine is.) “Was it covered last time?” (Again, shouldn’t they know that? And we all know that just because it was covered last time, doesn’t mean it will be covered this time) and my favorite “Well, all the plans are so different, we can’t possibly tell you what’s covered in your specific plan.” (They’ll certainly be able to tell me when I’m sent a huge denial of services notice in 4 months, why can’t they figure it out now, before I go, so I can plan it.)

Why can’t they look up my plan on a computer and say “yes” or “no” or “not that procedure.”

I know why they send the letter. . . but why would they keep sending it after you reply “No, there is absolutely no one else at fault for this”? Are they hoping you’ll change your mind? That you were lying? And how many times will they try? (I know that guy in the other thread got 3.)

Woo, classy!

Good luck. My soul is being held by consulting company I work for. You’ll have to fight them for it. Provided they haven’t actually consumed it at one of the board meetings of course.

In regards to their not being able to tell you if a routine physical is covered, they should be able to tell you if you’re allowed one under your plan’s guidelines. Otherwise, why do they have a CS line for you to call? They may be backing off of telling you specifics because they don’t know how the provider will bill it. Many times, a provider will provide a physical exam (routine), and then include a diagnosis code that points our systems to something non-routine. This happens a LOT. The CS person doesn’t want to commit to telling you “it’s covered”, as we coudl well deny the claim later (diagnosis code). I’m guessing, but that fits my Occam’s Razor thought.

Your insurer should absolutely know if your provider is In-Network or Out-of-Network. If you’re calling the provider, they might not know, or your insurer (UHC, for example) may have various network contracts, and the provider may be under one and not another.

To wrap it up, it sounds reasonable that all of your questions were reasonable for a CS person at your insurer. To confirm, you weren’t calling the provider’s office, correct?


It’s a “canned” letter. What this means is that we send it out whenever we get a claim sent in on your behalf. The better systems can see that you’ve already been sent one, and won’t send the second (and third, and fourth, etc.). Unfortunately, we don’t ypically upgrade systems for pieces that are non-critical (our wording, not yours). We spend tons of money making sure we can auto-adjudicate 90%+ of the incoming claims, but updates to the auto-letter system are few and far between.

When a claim comes in, it’s not one claim. Typically, you receive a claim from the primary doctor, the Lab, a Pathologist if utilized, Facility bills, Second Surgeon charges, and myriad other sources. You could conceivably receive 8-10 of these “other insurance” letters, based upon ho many claims we receive before we update your record (to “NOT” send out letters).


Nope, this was calling the number on the back of the insurance card.

And it has happened with every insurer I’ve ever had, not just the one I’ve got now, but several different large insurance companies.

It seems very strange that you would supply ID (SSN, “Alt-ID”, name, etc.) and not get directed to a CS person who could tell you what plan you were on, what your benefits were, and who could answer questions intelligently.

I don’t want to be pedantic, but did you call the number on the back of your card titled “Customer Service” (or something similar)? I know it sounds stupid, but we have several 800#s on the reverse of our ID Cards.

Unless you’re a person who doesn’t like to give out their SSN (entirely reasonable, in my book)? If so, you should have an “ALT-ID” field on the front of your card.


I have a question for you, and I don’t want to come into this to castigate anybody. I have Medicare Complete coverage through a very large insurer. I need a new card and have been trying to get one since the end of May. I have been calling every two weeks and have not yet received a new card. I have just made my fourth call to them in the last six weeks. The representatives are polite and apologize for the delay, and assure me they’ll have a new card sent to me, but I have yet to get it. To me this is ridiculous and indicates either a glitch in the system, or the system is so backed up that people are behind in doing their jobs. Either way, it smacks of poor customer service and I am considering switching my coverage. Do you have any tips to make sure I get my card? Would it help to ask for a supervisor or person actually in charge of issuing cards?

ETA: They do have my correct mailing address. I confirm that with them every time I call.

Well, you hit my first suspicion with your last sentence. It *could *be that they had the incorrect one for a while and are only now generating a new ID Card…maybe not.

A couple of things:
[li]Insurance’s dirty little secret: The squeaky wheel always gets the grease. I hate to say it, and it bothers me to say it, but if you run your problem up the ladder, it gets done. The reason this works is that most insurance companies have a tons of workers on the bottom of the pyramid, and fewer management thatn you migth expect. The Supervisor wants to get rid of you, and it’s easiest to get the problem solved.[/li][li]Some large insurers generate ID Cards by a “batch” system (especially Medicare plans, where it’s tons of individuals as opposed to one large entity). It could be that there’s a monthly batch run (usually run a January batch on or around Feb 5th, for example). It could also be a numerical threshhold (not nearly as common). If either of these are the reason, I’m guessing your first 1 or 2 tries failed, in that the CS person didn’t submit your request.[/li][/ol]

In the interim, check the insurer’s website to see if you have the option of printing off a temporary ID Card. It will be on your printer’s paper, but it will at least be current. Also, see if you have the option to order a “new” ID Card online. Online services often are far faster than going through a CS person. Why? The companies invest tons of $$ in web portals, and want them to be used. This way, insurance companies can build a strong case for reducing full-time staff.


Yes, that’s the number I call.

And again, this happens with many large insurance companies. You should try it with the one you work for and see if the CSR can tell you what is and isn’t covered with your insurance (call as a customer, not as an employee). While I would hope that yours is much better than the ones I’ve dealt with, you may be unpleasantly suprised.

As a matter of keeping on top of trends, I try to work in about 5 “secret shopper” calls per week (I’ll be honest…it works out to more like 10 per month). I act as an employee, and ask complicated questions requiring multiple system checks.

I was a little surprised at your gaps in service, because they’re what I consider to be “core” elements of insurance-company customer service. If I as a CS person, can’t tell you what your plan covers, then why is there an 800#? That seems like the very basement-level of a CS line.

My only thought is that you were asking about an upcoming procedure, in which case I woudl expect the CS person to beg off specifics. Until we have a bill in-hand, no-one should try tp predict payout.


Thanks for the answer. I will try to get a supervisor next time I call. I don’t think they print them in batches. They tell me “7 to 10 business days” to receive a card. And since I first called on the 25th of May, if they ran a batch in June, I would have had it by now.

I wish the company’s website had the option to print a new card or to order one online. I looked, and they have neither of those options. They don’t even have an option to send comments by email, just to request applications. They have no online service for current members, only prospective ones.

Why is it that we keep getting letters rejecting a claim because there may be another insurance company insuraing us, when there is none. There has never been another insurance company, but they still deny all claims until we confirm this fact year after year. But not every year, just to keep it perky, I guess.

Why must I constantly tell them I’m not insured elsewhere? Isn’t once sufficient?

It should be enough. However, it’s not, always. If it were a singly-submitted claim (let’s say for an office visit with no Lab work), then you should only have to answer once. If you have multiple providers submitting on “one” instance (e.g. Lab, Pathologist, Xray area, and Facility), then the system may trigger as many letters as there are individual providers.

Once your data is in the system (through receipt of the form or notifying a live Customer Service person), you shouldn’t have to re-send that information again for 6 months (fairly standard in the industry).

Why do we do this? First, we want to make sure the proper company is paying the costs. While this may seem irritating, we’re in a business environment, and need to know who’s supposed to pay. If a person is Medicare-age, we always send one of these letters out. If a person is of student age, we always send one out. If the member notified us that there was other insurance at the time of enrollment, we sometimes don’t get notified if that secondary insurance gets dropped.


Why all the “coding” mystery and mistakes? It seems to me that if my insurance plan specifically states that I am covered to have june bugs surgically attached to my eyelids that when I go in and get june bugs surgically attached to my eyelids that it should be covered. But then comes the “coding” - well, ma’am, that is covered, but it was coded as optical, not medical. We don’t cover that. Have you doctor’s office resubmit.

So basically, the rep is telling me they do cover the service that was provided, as outlined in my plan and agreed to prior, but since Judy in the doc’s office wrote a 3 instead of a 9 I have to end up in collections? Ahhhh! Why cover the exact same procedure for one reason and not the other if the outcome is the same?