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Health Insurance Guide
What Do You Do When Your Insurance Company Will Not Pay?
In these days of rising medical costs there is little doubt that a good health insurance plan can save you a great deal of money. However there are occasions when even the best of health insurance plans will fall short of meeting your requirements and there are many instances of individuals meeting with an accident or falling ill only to find that they are not covered.
Of course it is common for plans to exclude elective treatments such as cosmetic surgery, but there are many other areas of treatment that are often not covered. So, what do you do when your insurance company will not pay?
The first thing you should do is to read through your policy very carefully to see if the treatment in question is specifically excluded. If it is not excluded then you should approach your insurer in writing and ask for a written explanation of their reasons for denying payment. When their answer arrives, take it to your doctor and ask him for his opinion. In many cases you will find that your doctor can re-code your treatment and that a re-submitted claim with the new coding will meet with your insurance company’s approval.
If your doctor feels that it is not possible to re-code your treatment, and it is not specifically excluded, then your next step should be to appeal the insurance company’s decision. Each insurance company has a clearly defined appeals procedure that will be detailed in your policy document and you should follow this to the letter. Remember that your insurance company will be looking for reasons to reject your appeal and the simplest and quickest way for them to do this will be to say you have failed to follow the correct appeals procedure. It is also a good idea to seek the opinion and, where necessary, the assistance of your doctor in preparing your appeal.
If, in spite of your best efforts, you cannot get your health insurance company to pay the bill then there are still some options open you.
First, see if your doctor can negotiate a lower payment for your treatment or can authorize a payment plan. Also, find out if your doctor belongs to a medical discount program that you might be able to join. There are several discount medical networks with thousands of participating doctors.
If you have yet to undergo your treatment then shop around and see if you can find a suitable doctor who is prepared to carry out your treatment at a lower price.
Finally, don't forget to see if you qualify for free treatment at a public hospital or clinic. You will usually have to qualify on the grounds of your income or status (perhaps as a veteran) and it is surprising how many people ignore this option simply assuming that they do not qualify. It is also surprising to see the number of people, especially seniors, whose pride will not permit them to accept free treatment. If you are in need of treatment then park your pride at the hospital door while you have the treatment you need. You can always pick it up again on the way out.
Health treatment can be extremely expensive but, with some of persistence and a little bit of effort, you will be surprised how often you can get the treatment that you need at a price which you can afford.
Closed formulary: The provision that only those drugs on a preferred list will be covered by a PBM or MCO.
Functional status: A patient's ability to perform the activities of daily living.
Newborns' and Mothers' Health Protection Act (NMHPA): A federal law which mandates that coverage for hospital stays for childbirth cannot generally be less than 48 hours for normal deliveries or 96 hours for cesarean births.
Risk-adjustment: The statistical adjustment of outcomes measures to account for risk factors that are independent of the quality of care provided and beyond the control of the plan or provider, such as the patient's gender and age, the seriousness of the patient's illness, and any other illnesses the patient might have. Also known as case-mix adjustment.
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