Dealing with health insurance can be complicated. When you get care, you expect your insurance plan to cover the costs. But sometimes medical bills contain unexpected charges or denials of payment.
Understand Your Plan’s Benefits and Limits
All insurance plans have parameters around what types of healthcare they will pay for. The first step is understanding your specific benefits so you can use them fully. Key areas to review:
- Provider networks – Which doctors/facilities are in-network? Using in-network providers will mean paying less out-of-pocket.
- Covered services – What services, tests and procedures do your plan cover and are pre-approvals needed? Know what is covered before receiving care.
- Prescription drug coverage – Are specific prescription medications covered? What pharmacies can be used?
- Annual limits – What are the yearly limits on types of care like rehab visits or hospital stays?
Having clarity on these areas is crucial because exceeding limits or using out-of-network providers means getting higher bills. Also, be aware that plans only pay for care deemed “medically necessary.” Any care considered elective or experimental may be denied.
Stay Organized with Medical Paperwork
As you receive medical care, keep detailed records about all appointments, charges, and correspondence with healthcare providers and insurance companies. The people at Find-A-Code.com (offering medical codes, including ICD-11) say that important papers to retain related to medical billing include:
- Explanations of benefits – Documents sent by your insurer showing what they paid and any amount you owe.
- Itemized statements – Bills from healthcare providers breaking down each charge.
- Pre-authorizations – Approvals obtained from your insurer before certain services to confirm coverage.
Maintaining thorough paperwork allows you to cross-reference bills with your plan details to check accuracy. It also provides documentation if disputes about payment coverage arise down the road.
Review Bills and Explanations of Benefits Carefully
When you receive a medical bill, take time to thoroughly examine it along with explanations of benefits from your insurance company. Compare the two documents to identify any discrepancies in charges and payments.
Common issues to look for include:
- Being billed for services you did not receive.
- Charges that exceed what your insurer states is the maximum reimbursable amount.
- Duplicate charges for the same procedure or service.
- Out-of-network charges not being properly adjusted.
Detecting errors early allows you to contact both the provider and insurer right away to dispute problematic charges before paying incorrectly billed amounts. Having all documentation on hand also smooths the process of reconciling any problematic medical billing.
Appeal Denied Insurance Claims
Sometimes part or all of a medical bill gets denied by insurance. This could happen because the care is considered “not medically necessary,” or it was coded improperly by the provider’s billing department. Do not assume a denial is final; filing an appeal is often successful in overturning the decision.
The first step is contacting both the healthcare provider and insurance company to understand exactly why the claim was denied. See if the provider can resubmit the claim with corrected codes. If it continues to be denied, submit a written appeal request to dispute the decision.
Provide all documentation backing why the care should be covered, along with letters of medical necessity from your treating physicians. Be persistent and escalate the appeal to higher internal reviewers if needed. Many denied claims get overturned through in-depth appeals.
Conclusion
Dealing with health insurance and medical billing can quickly get frustrating. But staying proactive in understanding your plan’s coverage, maintaining detailed records, and appealing denials gives you greater control. Taking the initiative goes a long way towards receiving maximum insurance benefits and avoiding surprise medical bills.
