Health Insurance: Facts And Advices About Denial Of Payment
The nature of managed care health insurance plans increases the likelihood of a legitimate health insurance claim being denied. Take into the mind that managed care (health maintenance organizations and preferred provider organizations) exists for the purpose of controlling costs for the health insurance companies. A lot of different health care procedures, durable medical equipment, surgeries and drugs particularly much more expensive ones and require prior authorization from the health insurance plan before this plan will pay. Claims are reviewed to determine ‘medical necessity’ of this claim. Health care services or products considered ‘not medically necessary’ will almost certainly be denied for payment by the health insurance company.
Health insurance companies make mistakes and it is quite a real situation that a covered situation will be denied. What refuge does the health plan member have if one disagrees with the decision of the health plan? There are several steps to take in dealing with a denial of payment.
- Review the explanation of benefits sent you from the health insurance company. In the explanation of benefits must be briefly explained why your claim was denied.
- Review your particular health insurance policy. Look at what benefits the health insurance policy states for the certain service of product. Should your claim be covered according to your health insurance policy?
- Does your health plan have some special criteria must to be met for a certain expenses to qualify as ‘medically necessary’ and be considered as covered expense? For instant, a lot of different managed care plans cover drugs on their formulary. Other non-formulary drugs could be not covered at all or may be covered only in the case the formulary drug had been tried and failed. Check your policy to identify whether the expenses are qualified as ‘medically necessary’ by your health insurance company. Your health care provider has to collect all the necessary documentation for the health insurance plan to justify the need for the expenses.
- Determine whether your health care provider ‘in-network’ with your health insurance plan. If not, you have to determine whether your managed care plan covers ‘out-of-network’ providers. Most health maintenance organization plans do not cover the ‘out-of-network’ providers and many preferred provider organizations will pay for the services by ‘out-of-network’ providers, but at lower rate than paid to the ‘in-network’ providers.
If after the reviewing the explanation of benefits and health insurance policy, you are sure that the claim has been covered by the health insurance company, first of all you have to require in written form that the health insurance company provides your with the information that they used to base their denial of benefits. The health insurance company has a right to provide you with the information on request. Carefully examine these papers. Often the health insurance company was not provided with the appropriate documentation from the provider to justify the claim. In this case it is helpful to the provider to write a letter to support the claim in addition with the medical records.
It is very smart to do your own investigation on the health insurance market. You should pay attention to the health insurance quotes. Also pay attention to the conditions under which these health insurance quotes are provided. This will assist you to choose the best health insurance quotes provider.
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