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J.D. Van Nest & Associates Blog

Inside the Health Insurance Claims Process, pt 2


Filing a Claim

After you receive treatment, your doctor or care provider submits a bill for payment to your insurance company. When the bill is sent to your insurance company is it called a claim. The insurance company reviews the claim and processes it. Sometimes, depending on your insurance policy, you are required to submit the claim form yourself. For instance, if you have coverage through a Preferred Provider Organization (PPO) and you receive care outside the approved network of care providers, you likely will be responsible for filling out and submitting paperwork. You may also be responsible for filling out paperwork if you have indemnity/fee-for-services coverage. Don’t hesitate to ask your care provider for help with your paperwork. Though they are not obligated to assist you, they have great experience deciphering and submitting insurance paperwork and may be willing to help you.

Once your insurance company receives the proper paperwork, it decides whether or not the services you received are covered by your policy, how much of the cost will be paid to the doctor by the insurance company, and how much you will pay. In a worst case, they can deny your claim entirely.


Denial of Claim

A common problem with health insurance coverage arises when your insurance claim is denied or when you are denied a service you want and need. You are exposed to different kinds of risks and harm, depending on the type of insurance plan you have.

If you are a member of an HMO (Health Maintenance Organization), you are required to receive approval for the medical procedure and to pay your portion of the bill, your co-payment, before you receive the care. Denial of service for you, as an HMO subscriber, means that you are denied approval for a medical procedure that you want or feel that you need.

If you have coverage through a fee-for-services/indemnity plan or seek out-of-network care in a PPO plan, your insurance claim is processed after you have received the care. Denial, with these types of coverage, results in your provider deciding not to pay out on your claim. In some cases, you have paid the entire fee up-front, in other cases a portion. A denial of your claim either results in you not being reimbursed or being billed for the portion of your bill that remains unpaid.

Here are four common reasons your claim can be denied:

  1. You filled out the insurance forms improperly. Make sure you fill out forms completely and legibly.
  2. You did not file your claim in a timely manner. Your insurance provider places a time limit on accepting your claim. If you file your claim after the deadline, it will be denied. It is your responsibility to know your provider’s requirements and to meet them.
  3. Your treatment was excluded, per the terms of your policy. Every health insurance policy contains some treatments that are excluded. Again, it is your responsibility to know the rules of your policy, as you will bear full financial responsibility if you receive treatment that is not covered. Check with your insurance provider before you get the treatment, to make sure that you are covered.
  4. You received treatment without the proper approval and authorization. Make sure that you obtain proper approval and permission whenever it is required.


Reacting to a Denial

If you receive a denial, you have different options. Again, the type of insurance you have dictates the steps you can take. As mentioned above, the kind of denial you are likely to receive in a managed care plan is a denial of approval for a specific treatment, procedure, therapy, or medication. With indemnity insurance, it is likely the case that you already received the treatment and the dispute regards a denial from your insurance provider to accept your claim for reimbursement. In either case, the three main steps you can take are the same.


Internal Appeal

The first step is to make your case to your insurance provider directly. Speak with them to rectify the problem. If you are in a managed care plan, attempt to enlist your primary care physician to help make your case for why your treatment is necessary. If you have kept good records, you can bolster your case. Go up the chain of command at your insurance provider until you get a satisfactory answer. Keep all records regarding your dispute claim, too. Also, if you have insurance through work, see if your human resource benefits specialist can offer you any assistance.


External Appeal

If you do not get satisfaction, you can speak with your state’s insurance regulators. Medical insurance is a regulated industry in every state. Some states offer more aggressive protection for health insurance consumers than others. For instance, the State of California offers aggressive protection. In California, if you have a problem with your managed care provider, you can contact the California Office of the Patient Advocate, who can assist you by reviewing the health plan’s decision regarding your complaint.


Legal Help

Lastly, you have the right to seek a legal remedy. You can hire a lawyer and sue your managed care plan. Of course, this is an option of last resort. However, if you feel you have been wronged, it cannot hurt to speak to an experienced attorney. If you have a strong case, you likely can find an attorney that will work on a contingency basis, charging you only if she or he wins the case.



You pay a large amount for your health insurance. To make sure you do not waste your hard-earned money, take the proper steps to be an informed consumer. Know your rights and your responsibilities. You are your first line of defense. Take the time to understand how your policy works, what it covers and what it does not. Use your insurance coverage to improve your health and your life. Keep good records and follow-up appropriately, to make sure that your bills were paid by your insurance company. The more thorough you are in these areas, the fewer problems you will have.

Inside the Health Insurance Claims Process, pt 1


You probably do not enjoy going to the doctor or dentist. Dealing with your medical insurance provider and its paperwork doesn’t rank high on the list of fun activities, either. However, it is important for you to monitor the insurance claims process to avoid paying excessive amounts on your medical bills and to make sure you get the coverage you paid for.

Ideally, you will not have any problems with your insurance provider. However, because we live in a less than ideal world, you should take certain steps to avoid problems or to minimize the chances of problems occurring. You also want to be prepared to address a problem effectively, if one arises.


Be an Informed Consumer

Here are some steps to take, which will help you avoid problems and maximize your health care dollars.

  1. 1.Know your policy: Insurance coverage varies from policy to policy. It is up to you to know which kind of medical procedures and treatments your policy covers and which are excluded. Care that is not excluded can be limited. You want to know what portion of your care is covered. Are you obligated for a co-payment? If so, how much will it be? Are you obligated for co-insurance (a percentage of your treatment costs)? If so, what is the percentage? You should also know if you are subject to annual deductibles and, if so, what they are. Deductibles can vary within your policy, depending on the kind of treatment you seek.

2. Check with your insurance provider before treatment: Because it can be very confusing to know exactly how your coverage will apply, use your insurance provider and your health care provider to inform you. Check with your health care provider to get an accurate description of the care you are seeking. Then, check with your insurance provider to see how much of your treatment they are going to cover and how much you will be responsible for. It makes a lot more sense to check in advance. This will protect you from unexpected costs and also from paying for a treatment and finding out that your insurance provider is not going to cover it at all.

3. Keep good records: Whenever you speak with either your health care provider or your insurance company, keep good records. If you speak on the phone, note the day and time of the call as well as with whom you speak. Keep all written records, whether it is paperwork that you receive in the mail or something that is given to you during an office visit. The more detailed your records, the stronger case you can build if there is any dispute.

4. If you have managed care coverage, know who is in your network: Because you pay more for treatment outside your network, if you have a managed care policy, it is crucial for you to make certain that your provider is a member of your network. For instance, you could be in a hospital whose basic care was approved and covered by your network, but could end up responsible for some care if a non-network physician orders tests. Additionally, any time that you knowingly seek treatment outside of your network, make sure that you know your co-insurance responsibilities.

5. Follow up: If you are responsible for filing paperwork with your insurance provider, you should make sure that paperwork you send in is received and was processed as you expected. Don’t assume that everything you sent in was received and sailed through the system. You are the one who suffers if your paperwork was lost in the shuffle. You should be able to confirm that your paperwork was received with one phone call. If you receive a bill from your doctor or care provider that you felt was already paid, take immediate action by calling your insurance provider.



Consumers losing doctors with new insurance plans


Some consumers who bought insurance under President Barack Obama's health care law are experiencing buyer's remorse after realizing that their longtime doctors aren't accepting the new plans.

Before the law took effect, experts warned that narrow networks could impact patients' access to care, especially in cheaper plans. But with insurance cards now in hand, consumers are finding their access limited across all price ranges — sometimes even after they were told their plan would include their current doctor.

Michelle Pool is one of those customers. Before enrolling in a new health plan on California's exchange, she checked whether her longtime primary care doctor was covered. Pool, a 60-year-old diabetic who has had back surgery and a hip replacement, purchased the plan only to find that the insurer was mistaken.

Her $352 a month gold plan was cheaper than what she'd paid under her husband's insurance and seemed like a good deal because of her numerous pre-existing conditions. But after her insurance card came in the mail, the Vista, California resident learned her doctor wasn't taking her new insurance.

"It's not fun when you've had a doctor for years and years that you can confide in and he knows you," Pool said. "I'm extremely discouraged. I'm stuck."

The dilemma undercuts President Obama's 2009 pledge that: "If you like your doctor, you will be able to keep your doctor, period." Consumer frustration over losing doctors comes as the Obama administration is still celebrating a victory with more than 8 million enrollees in its first year.

Narrow networks are part of the economic trade-off for keeping premiums under control and preventing insurers from turning away those with pre-existing conditions. Even before the Affordable Care Act, doctors and hospitals would choose to leave a network — or be pushed out — over reimbursement issues as insurers tried to contain costs.

Insurance trade group America's Health Insurance Plans says studies show the biggest factor influencing consumer choice is price. Insurers say that if consumers want low premiums, their choices may be limited.

Insurance companies also argue there's wide variation in what doctors and hospitals charge, with some increasing prices every year. Insurers say there's little evidence that higher-priced hospitals or doctors are actually delivering better care.

Health and Human Services spokesman Fabien Levy says the law requires insurance companies to post their directories so consumers can see if their doctor is covered before they sign up. Officials say insurance companies ultimately decide what doctors and hospitals to include in networks, just as they did before the law. The federal government is closely monitoring plans to see if more guidelines are needed to ensure consumers have access to quality health care.

Insurance companies say doctors are equally responsible for letting consumers know what plans they accept. But finding that information can be tricky because healthcare.gov does not have a centralized directory of doctors and what plans they accept. Instead it offers links to directories of individual plans, which are sometimes inaccurate.

Insurance agents Craig Gussin in San Diego and Kelly Fristoe in Texas helped dozens of clients switch plans just before the enrollment deadline when clients realized their doctors weren't covered. Now, they're struggling to help clients who realized they were in that position after the March 31 enrollment deadline, when consumers are locked into plans for one year.

Gussin says that even after his mad-dash to make switches before the deadline, he still has a half-dozen clients who are stuck — and he expects the number to grow as more try to schedule with doctors. He and other agents fear it will be one of their most serious issues in 2014.

"Everybody I talk to is having the same issue. It's probably the number one item that we're seeing right now," said Gussin, who is petitioning Covered California for special enrollment status to help clients change plans.

Health counselor Nathalie Milias, who helped enroll nearly 300 Miami-area residents in ACA plans, says most of them chose a plan with $0 monthly premiums and deductibles — but with much more limited choices. She says tax credits could have allowed them more robust plans if they were willing to spend more, but many are working poor who didn't want to pay another bill.

Marie Bien-Aime, a 59-year-old cook at a Miami restaurant, enrolled in that plan to avoid a monthly payment, but she realized her longtime health clinic didn't take the plan. Shortly before the enrollment deadline, Bien-Aime upgraded to a plan that costs $37 per month.

"Paying $37 isn't good for me, but I had to do it because I wanted to keep my doctor because he's so good," said Bien-Aime, who was previously uninsured.

Many consumers are still learning. They hear "Obamacare" and think it's free like Medicaid or Medicare, said John Foley, an attorney and navigator.

"They don't expect to pay anything," said Foley. "For a couple more dollars a month you can get a really good plan and they're like, 'This is free. I don't want to pay for this.'"

Even with pricier plans, some consumers have access problems.

James Potts' $647-per-month silver plan was issued by the same company that had insured him with a different plan cancelled under the Affordable Care Act. The 64-year-old property insurance agent assumed his doctors would remain the same under the insurer's new plan, but didn't double check.

When Potts got a nasty cold, he called three facilities near his home in Wichita Falls, Texas, and was shocked to find none took the insurance, including his primary care doctor.

"It was a waste of money for me," he said. "I couldn't find doctors that would talk to me."


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