Nowadays, getting sick can mean a death sentence, what with rising costs and depreciating wages. No wonder people try to avoid illness as much as they can. But sometimes, it is not just possible. Getting hospitalized and receiving medications can be easier if one has health insurance. It can help a lot in managing the high bill you receive.
However, even with health insurance, you can be in for a rude surprise as your health insurance claim can be denied. You will be reeling in shock for the unexpected medical bills that your insurance should have covered in the first place.
But why does this happen?
Knowing the Nuts and Bolts of Insurance
One thing you need to understand first is that health insurance comes with contracts, which are often complex and lengthy. It is important to know the common terminologies that are often used and can help you better navigate the ins and outs of claims and complaints.
You should at least know the health-care providers stipulated in your contract. They can be the doctor, dentist, chiropractor, midwife, eye specialist, psychologist, physical therapist, nurse, and nurse practitioner.
Sometimes, knowing them can help you choose those who are qualified to help you with your concerns and get a lower fee for their service. For example, it is known that doctors are more expensive than physician assistants are. The latter can prescribe drugs as well and work under the doctor’s supervision. So it can be more sensible to acquire the services of the physician assistant if you only need a drug prescription.
Another reason is that there are certain professionals not listed under the health-care providers as defined by your insurance. This can pose problems as your insurance company won’t rightly shell out money if you hire a hypnotist.
Seeking Explanation from Your Insurance Provider
While it is a nuisance, you’re still entitled to an explanation from your insurance company. This is normally attained through the explanation of benefits (EOBs). Although most companies accompany your EOBs with keys to understanding the ins and outs of your insurance, there are questions that remain unanswered. Most of them provide a customer service number that you can contact for your questions regarding rejected insurance claims.
Reasons Your Insurance Company Fails to Pay Your Bill
Before you proceed to calling your insurance company to seek explanation, it is wise to come prepared by learning some of the reasons your insurance company may reject your insurance claims.
An Error from the Company
Insurance companies are not infallible from mistakes. In fact, they are quite notorious for inconsistent information that can have repercussions when it finally comes down to insurance claims. It is common for you to call your insurance company to verify whether a certain provider is part of your network only to find out later on that it is not and you are already billed with out-of-network services.
That is why it is important that you protect yourself by documenting every transaction you have with your insurance company, noting down the date, time, and call conference number. In the event that you have disputes, you can always back those up with proof.
There Are Non-covered Charges
There are cases when you overlook the terms of your insurance policy and undergo certain procedures that are not covered by your insurance company. These can be infertility treatments or dental surgery. If you want to be certain, you can review your policy and switch to a new plan that includes the care you believe you will need in the future.
Failure to Secure Preauthorization
There are preauthorization requirements that you need to secure before you can continue with certain procedures like CT scans or MRIs. This is requested by your doctor on your behalf.
There are two likely scenarios: your procedure provider will turn you away, or your claim will be denied after. Make sure you secure the necessary authorization before you proceed with particular tests.
Use of Out-of-Network Provider
One of the most common reasons when it comes to rejected insurance claims is the use of an out-of-network provider. Insurance plans vary, and there are stipulated provider networks covered by your plan.
Sometimes, it also happens that doctors accept your insurance but will send you a balance bill, which means you will take care of the charges that your insurance did not pay. To avoid this, you should never settle for a doctor’s verification whether their services are covered. Take it to your insurance company and verify.
There are also times that your insurance plan does not have any out-of-network benefits; hence, you need to pay a bigger share of the cost.
Coordination Benefits Mix-Ups
There is something called coordination of benefits, in which the patient has two or more health insurance plans. It is important to assign which insurance plan pays primary, secondary, and tertiary.
When these benefits get mixed up, your insurance claim can be rejected. Make sure you avoid this by updating your insurer with other insurance information and securing your estimate of benefits.
Failing the Drug Test
Although not common to all states, more and more health insurance companies require drug testing from their insurance holders. The cost of health conditions arising from drug abuse and rehab programs are often cited as the reason. Results indicating drug use can cause your company to deny your claims or ask you to pay for a higher premium. If you are worried about this, you can always test yourself to be certain you will pass a surprise drug test.
Health insurance claim denials are understandably frustrating, but you should remember that a denial does not mean the end of everything. An appeal is the next best course of action. Knowing the reasons your claims are denied will help you strengthen your case and have it overturned.
There are different appeal processes according to your plan, so make sure you read through them and follow each step. In the event that your company fails to resolve the issue, you also have the choice to request for an external review, such as from a government agency or a neutral third party.
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