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Health Insurance Claims

Health insurance claims can work one of two ways. Either your doctor’s office files your claim for you after you pay a pre-determined deductible or you pay for your expenses out of pocket and file a claim with your insurance company yourself and wait for reimbursement. The most common way is for your doctor’s office to file for you; however, to combat the expense of medical care (you are less likely to go to the doctor or hospital if you have to pay out of pocket first), some insurance companies are offering this option at a less expensive rate than standard insurance plans. Most claims, however, are still filed the traditional way.

Once you visit your doctor and pay your co-pay, your doctor’s office will file a claim with your insurance company. This claim will provide your insurer with a list of the procedures that were administered. The insurance company will review each procedure and make a determination as to whether the procedure was necessary. What’s more, your insurance company will determine whether the doctor is making a reasonable monetary claim for the procedure as well. Many people do not realize that their claims can be partially paid and they can receive a bill after the fact from their doctor for the difference in billing versus payment via the insurance company.

When you make a decision about your physician, you should always make sure that he or she is listed under your insurance company's recommended doctors. While there are some plans that have no list of required doctors (you can see whomever you want), this does not guarantee that your claim will be paid in full. You should always make sure that your doctor’s prices are not deemed unreasonable by your insurance company before you have any procedures or tests done to ensure you do not receive any unexpected or unaffordable bills.

If lab tests are conducted, the lab that tests your biologics will send a claim to your insurance company separately. This is often the catch 22 with health insurance claims, because you use a doctor approved by your insurance company you assume that all of the lab work is covered as well. The truth is the lab your doctor’s office uses to test biologics may not be covered by your insurance.

Lab work can be very expensive so it is very important that you ask your doctor which lab they use and verify with your insurance company that they are covered. If they are not then discuss with your doctor the option to send your biologics to a different lab, something that typically will not happen. You then have two options, you can switch doctors or you can get a prescription from your doctor for the required tests and go to the lab that is covered by your insurance in person.

Once your insurance company reviews your claim they can approve, deny, or partially approve the claim. If anything is denied the insurance company will inform your doctor’s office and will send you a letter stating the reason for denial. You have the option of challenging the rejection and requesting a review. Many times a denial is given because the doctor did not properly code the procedure. All insurance companies have codes assigned to procedures, if this is not followed correctly, it will result in a denial. A phone call to your insurance company will assist in quickly resolving this issue.

Other claims, however, are declined for very different reasons. The main reason a claim is denied is that the services that you receive are not covered under your insurance. Because something is medically necessary does not automatically mean that your insurance will cover it. You should always ask your doctor, his staff, and/or your insurance company if a procedure is covered before allowing it to be done. Often, if it is necessary, you can get approval for the procedure you need. This is one case, however, where you do not want to wait until after it is done to check on because you will end up being stuck with the bill.

Another reason that claims are rejected is because the procedure you had was not considered medically necessary or it was considered experimental. Insurance companies will not cover events that have not been proven safe and they are not in the business of covering procedures that are not necessary for your health or your survival. Plastic surgery is an example of a procedure not covered by your insurance company.

If you believe that your claim has been denied unfairly, you can protest with the insurance company, file a request for review and eventually or, if all else fails, you can file a request for review with your state's department or insurance.

Knowing your health insurance company’s rules and limitations when it comes to your care will ensure that your healthcare costs remain at a minimum. Knowing the process will also help you regulate your healthcare costs. If you are unhappy with your health insurance company due to past performance or lack of coverage, you owe it to yourself to discuss your needs with our independent agents. Or, you can compare top health insurance companies by using our quote tool at the top of the page and find a company that fits your health needs and your budget as well. Why not take your new knowledge of health insurance claims and get some free health insurance quotes right now?