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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.



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