By Martine G. Brousse (not AI)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
March 19, 2025
It seems that insurance companies, having too much time on their hands now that AI has taken over, are placing more and more hurdles on accepting Out Of Network invoices for reimbursement, let alone paying them.
This blog focuses on recognizing potential reasons for rejections and on how to fix them from the start.
A. The Out Of Network (“OON”) Dilemma
1. The Billing Cycle
· As an OON provider has no legal requirement to bill your insurance directly, they can (and do!) ask for payment up front. Once paid, an invoice, claim form or superbill is generated
· You submit that document to your insurance to get reimbursed
· In too many cases, those invoices, claim forms or superbills are either lacking required information, showing incorrect codes or data, or are printed in a format which the AI systems cannot read
· If the system cannot accept the invoice, claim form or superbill, it cannot pay it.
If the provider does not issue complete, legal and valid invoices, claim forms or superbills, you are out of luck… and out of reimbursement money.
2. Major reasons for rejections or inability to process:
· Untimely Filing: each policy allows a certain number of days during which an OON invoice can be received for processing. Most plans allow 365 days from the date of service (NOT the date on the invoice!) but a trend has been to reduce that limit to 180 days from the date of service.
· Need Proof of Payment: Although the mention “paid in full” or how much has been paid by the patient is indicated on these invoices, claim forms or superbills, a newest trend is to demand actual separate proof in the form of a credit card receipt, cash receipt, Venmo print out or cancelled check.
· Illegible Format: Odd rejections that make little sense often follow AI’s systems’ inability to “read” an hand written invoice, claim form or superbill, or invoices generated via non-medical platforms such as Quickbooks. Even if all the needed info and codes are listed, they have be labelled or placed in a different way than the system has been taught to find. A good example is a rejection for lack of a Tax ID# (“TIN”) because the number is listed on the invoice as “TID” (Tax ID)
· Inability to upload the invoice, claim form or superbill leads to frustration and reimbursement delays. This especially occurs when dependents are not listed on the portal, or cannot be added without a special authorization (CA law for example). In some cases, only HR can add a dependent or give access on a parent’s portal
The ability of the insurance systems to accept, “read” and process your claims (properly!) is showing trends of inadequate programming, rejection default, incorrect denials and unnecessary hurdles which negatively affect your ability to get prompt and maximum reimbursements.
B. Help Yourself
1. Stay Timely
· Check your policy: it will indicate how many days are allowed for submission of claims
· Gather then submit invoices, claim forms or superbills on a monthly basis. It is easier to keep track, and encourages providers to keep timely accounting records
2. Attach Proof of Pay
· If asked once, expect to be asked for every single invoice
. Your bank portal will help you download a credit card transaction, or a Venmo payment
· The provider may be able to give you a separate list of “Paid” transactions for the month corresponding to the invoice, claim form or superbill
3. Don’t get stuck on the portal rejecting your upload
· Submit your invoice, claim form or superbill via fax to the Claims dept, email to that Dept or even snail mail. The insurance website should have all this info under the Contact tab. The mailing address for Claims is always listed on the back of your insurance card. Another avenue is to send a Message through the portal message center and upload the invoice, claim form or superbill there.
4. Contact IT or HR to get Technical Support, IT issues fixed, the portal updated, dependents’ info added and upload glitches taken care of. The Message Center on your portal can be helpful as well.
C. Tips
1. Learn what a valid invoice, claim form or superbill looks like! I have blogs and videos to help you figure that out.
2. Demand correct, valid, legible, complete invoices, claim forms or superbills from the office. Because they already got paid does not discharge them of the responsibility to help you get reimbursed. Accurate Billing is actually a requirement under a provider’s medical license.
3. File Complaints if denials or rejections are due to insurance systems’ errors or mis-programming
· With HR especially if your plan is self -funded (your employer pays the insurance to administer your claims but makes its own policy)
· Through messaging the Message Center on your portal
· Through your insurance’s Grievance or Appeal Process
· With your State’s Dept of Insurance or insurance regulatory agency
· With your State’s Attorney General’s office if too many complaints do NOT result in improvement or if delays and errors appear more willful than incompetent.
The more patients complain, the better the chances of improving unfair, uncaring and too often uncooperative systems!
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2025 @ the medical bill whisperer 2025™
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