So yesterday, I shared with you the reason I decided to do this piece in the first place. As I mentioned, I still believe that most insurers have every intention of doing right by you- but that being said- things can still go wrong. As I set about trying to resolve our issue with our insurance rejecting Donna’s entire hospitalization, I spoke with people all over the place- claims adjusters, claims evaluators, insurance agents, billing experts- you name it. I wanted to approach this problem with as much ammo as I could- after all, it was that or find some way to earn an extra $260K.
Here are some of the most useful tips I compiled:
-First of all, when you get a denial of payment for a medical insurance claim, don’t panic- you need to have a clear, methodical approach to getting the issue resolved, and freaking out will not serve your needs.
-When you get health insurance, or make changes to the policy you have, get an actual copy of the policy, and take some time to review it. I am always surprised when I discuss issues like precertification with patients, and they have no idea what I am talking about. Pay particular attention to clauses which might result in an exemption. It was one of these small, innocuous looking clauses which resulted in Donna’s denial of payment.
-Periodically, you may get updates, amendments, or addendums to your policy in the mail. It can be easy to overlook these and throw them in the trash. As insurers try to tighten their belts, you may find that services that were once covered, no longer are. Keep these letters in a notebook with your policy so you can remain current on what is covered and what is not.
-Know what your deductible is- again, this sounds obvious, but many people are not aware that there can be different deductibles for different services. Outpatient services may have one deductible, and hospitalization may have another, and deductibles from one ‘pile’ usually don’t apply to the other. This is important so you don’t get any unwanted ‘surprises’ when your explanation of benefits and subsequent bill show up in the mail.
-If you have been rejected for payment for a service you thought was covered, look over the explanation of benefits (EOB) statement you will get from the insurer, and find the codes they used to justify the denial of coverage. Be sure that code applies to your situation- the EOB is not the final word on your coverage, and sometimes a billing specialist will mis-key an entry resulting in your denial. A simple mistake could cost you a lot of money if you are not paying attention.
-This is a big one: If you have been denied coverage for a medical condition, or a diagnosis which for some reason is not covered by your policy, get ahold of the records regarding that service (the office notes, chart- whichever) and schedule a time to discuss the care with your physician. It is likely that your doc wants to get paid for his/her good work, so they will usually be happy to take the time to review the chart with you, and if needed, produce a letter explaining why a service was medically necessary, or why a specific diagnosis should not be exempt from coverage. This may take some time, but will be well worth the effort.
-In the same vein, if your denied claim has been reviewed by a medical reviewer, be certain to get a copy of their report and review that with your physician so that you may be certain that their findings were not based on a misconception or error.
-Be sure to document all of your phone calls to representatives to the insurance company, and keep copies of all of your correspondence.
-If you have a claim that is under review, be certain to get a letter documenting the review, and provide it to any of the providers who may be billing you. This will prevent your bill from being sent to collections while the appeal is under review.
-If all else fails, you are unable to resolve the issue, and are faced with a difficult or unpayable bill, contact the billing office of the physician you owe, and explain your situation. Many offices will offer a reduced payment, or perhaps a payment plan to help make things a little more manageable. I know this option isn’t optimal- but at least it can reduce the pain a little.
I hope you never have to deal with one of these complicated situations, but if you do- I sincerely hope these suggestions will provide you some assistance.
Thanks for stopping by,
Andy
'Doors' by Steve Tobin (stevetobin.com)
