Insurance World

If you are like most people, when your medical insurance declines your claim, you are left feeling helpless and frustrated. After all, if you need health care and your insurance is saying you don’t, you have two choices – appealing your claim or paying for the treatment out of pocket.

Most claims are declined for specific reasons and causes. The most likely cause for your health plan to deny your claim is a direct consequence of missing data. Before appealing your denied claim, you can verify that by assuring any and all pre-authorization requests were filled out with accurate patient information.

For example, is your social security number correctly listed? Does the doctor have the most current copy of your health plan’s identification card? Does your doctor have the most up to date copy of diagnosis and procedure codes in order to fill out the forms correctly?

By verifying that you have submitted the good documentation to the physician and they in turn submitted good documentation the health plan, you are ready to move to the next level. When it comes to dealing with your health insurance company, think paranoid.

Document every phone call, every contact person and every piece of information you are given. It only takes one break down in communication to cause a problem; by documenting all of your communication with the insurance company, you are pre-preparing for any appeals case.

If you are facing an appeals claim for treatment coverage, be sure you’ve reviewed the appeals process in your company’s health insurance handbook. Most patients overlook reading through the handbooks their insurance company will provide. Plan requirements and appeal processes are detailed in these handbooks and you should make sure that your plan covers any treatment you are going to receive before the treatment is received, if possible.

When An Appeal Is Necessary

Since every plan should have a clear appeals process, you should follow it explicitly. You should talk to your doctor about appealing the claim so they can provide supporting documentation and expertise as needed. Remember, most insurance claims must be appealed within a limited amount of time, so if you wait six weeks after a denial and you only have 60 days to appeal; you may already be out of time.

You should always appeal internally to your insurance provider before going to an external source such as a government or state appeals process. Most appeals have a process that goes as follows:

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Phone Complaint
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Written Complaint
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Written Appeal

This is another area where you should be very specific citing the coverage rules of your plan as well as documenting each contact you have with the insurance company. While the insurance carrier will approve the majority of valid appeals; there has been documented cases of insurance fraud and health plans that do not play by the rules. By documenting response times and any required response times; a patient can exhaust their option against the insurance carrier for a valid appeal and then take it to the next level.

Laws in many states govern an appeal to a state or federal insurance oversight process; these requirements often allow for an external, expert review of the appeal. By providing accurate documentation and detailed medical support from your physical, a board of qualified experts can then judge your case on an individual basis. If an external appeal validates the claim and overturns the denial, then your insurance company will not be able to deny the claim.
Knowledge of your health plan, your doctor’s knowledge of procedures and a detailed review of the appeals process are your best tools to getting the approval of the treatment you need. Do not overlook the details, keep accurate documentation and review your coverage plans if you have any questions. Remember, there are always options.

At present there are nearly 45 million Americans who do not have health insurance. Are you one of them? There are several reasons why people do not buy health insurance. The prime reason and most obvious is the cost. On the other hand the cost incurred to you and your family if you are not covered by insurance and are struck down with a major illness unexpectedly may mean complete bankruptcy. Another top reason why people do not acquire health insurance is when they change companies and have a pre-existing condition. Often times a new company will not insure a person that has been diagnosed with an illness or chronic condition because they are considered a high use risk. Then again some companies may want you to buy health insurance but they do not necessarily want you to use it. There are a number of alternative programs available in nearly all States in the United States that offer plans to people that have been denied insurance due to a pre-existing condition. However such types of programs are not always well publicized but definitely worth looking into if you or a member of your family falls into this category, and not an option to overlook as you buy health insurance.

There are a variety of companies and options to buy health insurance. Several major companies offer a free on line quote. These companies not only offer an in-depth comparison for the various plans offered within the company but also comparable prices of similar plans offered by their major competitors. The comparisons usually look at the type of deductible you are willing to pay as well as co-pays. The key flux in price from one plan to another is whether or not prescription medications are covered or offered at a reduced rate with co-pay. When you decide to buy health insurance prescription coverage may not be necessary if you or your family members are not prescribed daily medication. Whereas the elderly who are more liable to have prescribed medications, have Medicare options to cover this area, hence this is not as important of an issue for them when buying supplemental health insurance to pick up where Medicare ends. An important thing to remember is to fill out the state you currently reside in if you choose to have a price quote done when filling out the information for United States Citizens as at this time you can only buy health insurance from providers from the State you reside in. Though currently there is a bill in legislation trying to amend this policy; still there is not a great deal of support for it. The state of Massachusetts is trying to pass a law that it be compulsory for all residents of that state to buy health insurance or face penalties, similar to the mandatory laws to have car insurance. However the major debate that exists with this type of legislation is what is affordable to one household may not be affordable to another.

The crisis of millions of Americans without health insurance is costing tax payers millions of dollars annually. Individuals and families need to be protected so buy health insurance. On a positive note, if every person does buy health insurance the over all costs for everyone will decrease, as those with insurance need not incur higher cost for premiums as the result of paying for the costs of those who do not have health care coverage.