Navigating Challenges with Self-Funded Programs
I’ve experienced ongoing issues since my company switched from Aetna to Cigna’s self-funded open access plan. Each month, I submit claims for reimbursement for out-of-network services, and while the diagnostic codes remain consistent, I find myself facing the same frustrating obstacles multiple times a year. Claims often get lost, remain pending for weeks, or are marked as missing information—even though I provide the same details each month, just with updated dates.
It often feels like I’m being put through a frustrating game, with the insurer trying to avoid payment. I’m wondering if there are any avenues to escalate these issues. Unfortunately, my company’s care advocate hasn’t been much help, which leaves me feeling stuck and seeking other options. Any advice on how to address this would be appreciated!
I understand how frustrating it can be to deal with claims issues like these, especially when the same information seems to be getting lost or mismanaged. When you’ve exhausted your company’s care advocate as a resource, there are a few steps you can take to escalate the issue further:
Document Everything: Keep a detailed record of all your interactions with Cigna, including dates, names of representatives, and what was discussed. This documentation can be crucial when trying to escalate the issue.
Contact Cigna’s Customer Service: Sometimes, reaching out to a higher-level customer service representative can yield better results. Ask to speak with a supervisor or someone in a claims resolution department.
Formal Written Appeal: If your claims continue to be mishandled, consider submitting a formal written appeal. Be sure to include all relevant information, copies of previous claims, and any correspondence you’ve had with Cigna.
State Insurance Department: If you’re still not getting anywhere, you can file a complaint with your state’s insurance commissioner. Each state has its own insurance department, and they can often intervene on your behalf.
Employee Benefits Division: Contact the employee benefits division of your company. While the care advocate may not have been helpful, someone else in HR or benefits may be able to take your case more seriously or escalate it on your behalf.
Professional Help: If all else fails, you might consider consulting with a medical billing advocate who specializes in navigating insurance claims.
Remember to stay persistent and keep following up. Sometimes, simply making it clear that you will not give up can lead to a resolution. Good luck!