10 Steps You Can Take to Get the Coverage You Deserve

Health insurance coverage costs are rising at an alarming rate. According to a 2005 survey conducted by the Kaiser Family Foundation, employee premiums have increased 70% since 2000. During the same period, wages rose just 15%.

Unfortunately, while insurance costs are rising, the medical claims processing system remains highly complex, resulting in individuals not receiving coverage they deserve. Consider these statistics from Medical Economics:

• 31% of all medical claims are delayed
• 20% of all medical claims are denied
• Denied claims typically take 3-4 months to resolve

In this time of rapidly increasing out-of-pocket medical costs, it is important that individuals do all they can to get the coverage they deserve from their insurance provider.

Increase your coverage

Here are 10 things you can do to make sure you get the coverage you deserve.

1. Review Your Evidence of Coverage or Policy Disclosure Document
   Every insurance company has information on what is covered and what limitations there may be for specific medical treatments. You should have received an Evidence of Coverage or Policy Disclosure document when you obtained your policy. Review this document to understand your coverage, deductibles and limits. It is very important to understand the limitations of your policy, so that you can plan accordingly and discuss options with your doctor. If you have questions about your coverage always call the insurance company for clarification.
2. Bring Your Current Medical Insurance Information to Every Visit
   Many of the problems we experience in getting coverage are due to improper insurance information. Most receptionists will ask for updated insurance information, typically a card provided by the carrier, but don’t wait to be asked. Have your card or cards ready when you arrive. Make sure you understand where claims need to be sent and also give this information to your doctor. For example, if you have an HMO plan, your claims need to be sent to your medical group and not the insurance company.
3. Ask Your Doctor if They Bill Your Insurance Directly
   Most doctors’ offices will bill your insurance directly, but some don’t. Ask your doctor’s office if they will bill your secondary or tertiary insurance. Keep a notebook and record their answer for your future reference. If your doctor does not bill directly, make sure you receive a detailed bill with complete procedure and diagnosis code information. You will need to send this information along with a claim form to your insurance company.
4. Ask Your Doctor to Verify that You are Covered
   Many insurance companies have limits or specific benefits for specific procedures and conditions. Most doctors are knowledgeable or have back office billing staff that can check with your insurance provider to make sure you are covered for your visit or any resulting procedure. For some procedures doctors are required to obtain pre-authorization by the insurance carrier. Make sure you get this prior to all major medical procedures.
5. Submit Your Claims in a Timely Manner
   Most Insurance companies have time limits for submitting claims. If your doctor is submitting your claim, make sure it has been sent in and is being processed in a timely manner. Make sure you have the most current claim forms and billing addresses available. Forms can be found on most insurance company web sites or can be mailed.
6. Review Your Explanation of Benefits Statements Carefully
   After a claim has been submitted to your insurance provider, you will receive an Explanation of Benefits (EOB) statement. Review this carefully as it details what is covered, what is not, what is applied to deductibles and in what amounts. If you don’t understand any information on this statement, call your insurance company for clarification.
7. Always Contact Your Insurance Company Quickly with Questions
   It’s important to quickly contact your insurance carrier with any questions. Many providers have time limits for handling disputed claims. Have your policy information handy when making your calls so you can have the agent research any specific coverage issue you may have. Remember to document every conversation and take down the agent’s name if you have issues.
8. Be Persistent and Courteous with Customer Support Agents
   Often times the insurance agent taking your call has to wade through a great deal of policy information to answer your specific question. Take the time to make sure they understand your issue. Be persistent to insure you are getting the appropriate attention, but courtesy will often result in an agent being more sympathetic to your issue. Don’t underestimate the power an agent has in slowing down or even denying your coverage, or, better yet, getting your claim re-processed for additional benefits.
9. Understand your Prescription Benefits
   Check to see if medications are covered under your health plan. If you have prescription benefits take care to understand their “generic prescription” policy. Many insurance companies cover generic brand prescriptions at a higher rate than brand name prescriptions. Ask your doctor about prescribing generics. Read the exclusions list to see if your current medication is not allowed. Do not forget about your secondary and tertiary insurance policies. They may have some prescription benefits for you.
10. Know About Resources Available to Help You
    There are third party resources available to help you. First, the Internet is full of information on medical insurance, beginning with insurance company web sites. Medicare has a good support center available through a toll-free number. Their website is also useful, www.medicare.gov. In addition there are agencies, such as HICAP, who can provide limited free assistance. In cases where you need an advocate, there are local claims specialists you can contact.

It is important not to give up when you experience a problem with a medical claim. Take the time to carefully understand the issue and present it clearly to your insurance company or doctor. With patience and persistence you will be surprised at how many of your medical claims can be covered with some additional benefit to you. One way to manage the ever-increasing costs of medical care is by being an informed health care consumer.

 

About the Author : Clarissa Odell, Claims Relief Solutions

Clarisa Odell has over 15 years experience with medical claims processing and specializes in helping individuals manage their medical claims. For more information contact her at clarisa@claimsrelief.com or visitwww.claimsrelief.com. © 2005 Clarisa Odell, Claims Relief Solutions™