A Day in the Life of a Claims Examiner-- Part One

Insurance Guru

I've had this rant bouncing about my brain for many years. I processed health insurance claims for several years and trained examiners for a couple more.

There seems to be a perception out there that examiners are routinely told to deny, delay or otherwise hinder paying claims so that the Company can hang onto its bucks for some nefarious world domination scheme.

I've worked for four, very large insurance companies and this has NEVER been a policy. Who wants to work a claim more than once? A claims shop is all about inventory and days on hand. A claim that's been in the shop over 10 days will have someone stopping by your desk and tapping a toe until it's processed.

We are also people. The claims that create the most difficulties to process are, of course, the ones for the most catastrophic cases. The last thing we want to do is add stress to patients and families by not doing everything in our power to get that claim paid. We had an informal rule that if a claim came in for a patient now deceased, it got paid. Now. We would run it up the food chain until it got released by whomever had the security to get it past whatever edits we were facing.

The average claims shop is not run by Scrooge McDuck nor is it full of claims processing Gremlins with popcorn bags on their ears. They are just like me and want nothing more than to process your claim timely, accurately and only once.