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Health & Fitness

Community Update

 





If you’ve used your health insurance
to cover non routine care lately, chances are you’ve found yourself entering into an
unchartered territory of misinterpretation and confusion.



As an insured with a high deductible
plan from a large health care organization, I have been residing within a hazy terrain,
questioning the view of claim processing incompetence or fraud, for the last
four years.

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So while Administrators might be
addressing the intricacies of Obamacare benefits, it’s time for us common folk to
share some proactive practical applications for getting those
medical bills processed correctly.



It’s no longer enough to simply buckle
up your seat belt, to get:

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·        
Familiar with your insurance policy;



·        
Confirm your providers are in network;



·        
Keep detailed records; and



·        
Find out how to obtain special
authorizations.



Consider these only start the engine
activities. Now expect mechanical difficulties.



First advice, pour yourself a big
glass of lowfat or skim Strawberry milk to enjoy as you call your insurance
company, it is the only Quick (as in Nestle) you will get, within the context of claim processing, for quite a awhile. 



Plan to stay on the phone with your
representative(s), restating the same basic data, reiterated a mere 40 seconds
previously to a different representative(s), who probably sits in an adjacent
cubicle.  “Hey, I just told this
information to the person I just spoke with” I say, Do you think I was
fibbing?  I still live at the same
address I did 45 seconds ago, with the same phone number, group number, ID
number and date of birth; imagine that. Here let me put you on speaker phone to
answer your questions while I go to the bathroom. -Okay, that is a little
crude, especially for this degree of inconvenience.



Most insurance representatives seem
nice.  The difference is they are working
and enjoy their free time.  I on the
other hand sit on my haunches for hours, contemplating getting into the
chocolate stash and  wine, because of the
frustration of spending my free time deciphering  their paperwork that communicates on
processing of claims that are, optimistically, correct about 65% of the
time. 



It’s a drag, and for that matter, it’s
more than a personal bummer, what we spend on healthcare and processing of
costs, are funds tied up from spending in other areas of the economy.



Below are some of the we wish we knew
when we started scenarios:



 



·        
Check your summary numbers
monthly.  Our insurance company often
assigns claim costs to the out of network (15,000 per year, out of pocket max)
deductible instead of the in network (11,000 per year out of pocket max)
deductible.  This translates into your full
responsibility for payment for claims that should be covered.



 



·        
Medical services can be billed in
segments.  For example, although your
provider confirms with your insurance company 32 authorized treatments, this
does not necessarily equal the total amount of visits.  An authorization for 32 visits of physical
therapy could actually mean you have one 45 minute visit that entails 15
minutes of manual manipulation, 15 of electrical stim, 15 machine exercise,
resulting in each segment billed with a separate code.  Your insurance company will determine 32
treatments have been reached when you are done 10 visits.



·        
 When calling a representative the first
question they will ask is which claim you are referring to.  Unfo
rtunately, although health insurance companies
are in full charge ahead mode to get new customers and revamp their  websites, our insurance company website does
not reflect the detail for out of network  processed claims.  When they ask which bill and date of service,
I am unable to tell them which claim they arbitrarily selected to be assigned
out of network deductible status because 
the system does not identify them to the insured.  (They simply provide the entire amounts)  I agree to wait while they look through every
claim processed this year and last.



·        
When your dependent goes to college,
find the nearest in network provider to their university. If they need any type
of care and go to the university health clinic, it is often processed as an out
of network provider.



·        
If you go to a doctor in a group, who
is the sole in-network provider within the group, speak up to make sure claims
are processed under the doctor’s name and not the medical group name.  Often we have had the insurance company view
the claim under the group name, and thus assign it out of network status.



·        
If you need to see a doctor that is
one of the few in the local area that specializes in a specific type of medical
condition, but is not an in network provider, some heath insurance policies
have exception authorizations.   But know
that the claims department (for every out of network claim we submitted) did
not have the authorization number on hand. 
Which means claims were always processed as out of network, requiring
repeated phone calls, additional documentation, appeals.  A process that can stretch from months to
years.



·        
Many out of network providers require
you to pay up front.  When the insurance
company processes the payment, they will send the check directly to the out of
network provider.   Keep further evidence
of your personal payment, ( minimum two years back), in order to begin to
follow up for reimbursement from the service provider.



·        
Do not submit a claim for an out of
network specialist through the online system. 
It must be submitted by mail and have the authorization number on
it. 



·        
Don’t be alarmed if you receive an EOB
with a code that confirms that the claim was denied because the provider did
not get the information into the insurance company to process it in a timely
basis.   This EOB code can be received
for a claim that is only six weeks old. 
I interpret it to mean they need more information and want us to get it
for them.



·        
Write down all 22 character reference
numbers, from every phone conversation, correctly.  Practice: 453937585648-575764-49;   4j5738trjfyw0e848-3y4jdue;
3ufnntfle84-4u74nn-eeeg28.



Good luck.

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