September 22, 2017


Best Practices - Insureds

Prepare the Claim 


1. Understand your health insurance - Read your plan coverage booklet when your body and mind are healthy. Don’t wait until you’re too sick to understand your coverage. It only adds to your stress. This may sound obvious, but you'd be surprised how many people don't know how much they have to pay or what they have to pay for. You may need to read some sections more than once. If you have questions, call your benefits manager or customer service. When your coverage is clear to you, you'll feel more confident, and you'll reduce the possibility of erroneous and needless insurance company denials later.
  
2. Gather your insurance information -  Know the policy structure. Know how much your deductible is and the services to which it applies What circumstances require a co-pay? Plans vary. Some require a co-pay only at the doctor’s office and not for lab visits, so it's important to be familiar with the conditions. Pay your co-pays at the time of service. When you enrolled in your plan, you became contractually obligated to do so. This will reduce the number of bills you receive. Pay with a check or credit card so you have a record.
 
3. Ask questions prior to your visit - Check with your insurance provider and doctor beforehand. 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. This will protect you from insurance company denials and unexpected costs due to paying for a treatment and finding out that your insurance provider is not going to cover it.

4. Get itemized receipts - Ask the provider for an itemized bill that lists every service. 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.  
 
5. Obtain claim form - Contact the insurance company to obtain a current health insurance claim form. And 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.
 
6. Make copies of everything -  And pay only what you owe. If you're like most people, you probably don't want to deal with medical claims and insurance companies. But if you don't deal with them, you're opening the door to problems later on. Do not procrastinate on managing your medical bills and insurance claims. If you don't take care of them promptly, you're asking for trouble. When you get a bill from your doctor or a notice from your insurance company, open the letter and read it. If you don’t understand it, call and ask questions. Be proactive to avoid insurance company denials!  
 
7. Call the health insurance company - If there is anything that you don’t understand, call and ask questions. Be proactive! Prior to calling, in order to understand your EOB if it's not clear, approach it this way:
  • Look for the facility or provider’s name. Sometimes it may be a name you don’t recognize. The date of service will help you recall what appointment you had and whom you saw.

  • Find the date of service.
  • Look for the total charges.
  • Subtract the amount the insurance paid. Sometimes the insurance pays you; sometimes the insurance pays the doctor. If there is no check attached, that means they paid the doctor. If there is a check attached, that means they are paying you and you have to pay the doctor.
  • Subtract the patient responsibility. This is indicated on the EOB in the columns for co-payment, co-insurance, and deductible.
  • The remaining figure is the amount the doctor must write off. You should not be billed for this amount.
  • Write your check to the doctor for the patient responsibility amount less the co-pay you were obligated to pay at the time of service. If an insurance check was attached to the EOB, add the amount of that check to your payment. Write the date of service in the memo section with your account number from the doctor’s office. If you handle this promptly, neither the doctor nor his staff will have to follow up with you. They'll have more time for patient care rather than paperwork, you'll receive fewer bills and it'll be more convenient for everyone.

8. Institute tracking system - 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 and less likely insurance company denials will take place.

9. Organize provider statements as received - 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.
 

10. Check everything against Insurer monthly statements - Since insurance records are really important pieces of paperwork, you need a solid system for keeping it all organized. You should get EOBs after the insurance processes each claim for each provider. If you don't go to a doctor for 3 months, no EOBs for 3 months. If you go to several doctors in a month, the EOBs should trickle in as the insurance company processes that claims.That being said, most insurance companies are lousy with getting the eobs to the patients. Aside from claims information, most insurance policies don’t generate a huge amount of paperwork. 

 

Related Resources:
 
1. "Get Help Using Insurance", HealthCare.gov (2010)
 
2.  "Tips for Saving Money on Your Health Insurance", Jean Marquit, Yahoo.com  (2009)
 

   
A basic tutorial on health insurance to help you to avoid needless insurance company denials.