Health insurance is our bulwark against emergency medical expenses that can hit hard, anytime in life. However, in such a scenario, where one has gone through prolonged hospitalization, if one faces a denial of insurance coverage, life can be really tough.
Statistics related to denial of claims are not disclosed by health care insurance providers in the USA, but it is a fact there are millions of claims, which are rejected every year. Insurance denial is a reality which people have to suddenly face when they have no information about the insurance policy rules and regulations.
What are the major grounds on which a denial is met out by insurance companies, is not very clear. This issue has been in public debate for quite some time now and many people have demanded more transparency from health insurance providers, in terms of disclosure about denial statistics. Ergo, one needs to be very careful and read the rules and regulations of a health insurance policy. Be clear about what they promise in it.
How to Prevent a Denial?
All health insurance coverage policies come with certain inbuilt restrictions about the conditions under which you will be eligible for that insurance cover. Here are some points and tips to remember while availing health care facilities:
Check Referral, Network, and Pre-Authorization Restrictions
Most insurance policies have guidelines and pre-authorization requirements regarding which health care facilities you can take treatment from. The cover can only be restricted to certain health care facilities which are part of their affiliated network. They may also have separate guidelines regarding referrals. All this information is usually provided in the coverage certificate details.
Make sure that you are aware of these restrictions as in case you have taken the treatment, outside the affiliated network, you may be denied cover altogether or offered a reduced cover on those grounds. Often, the insurance companies require you to register a doctor as a primary physician. Make sure that you list one and the physician himself has been informed of this. Read what are the clauses regarding emergency medical needs. Contact the insurance company help desk for clarification, if required.
Ensure Authorization of Referrals
When taking consultation from any physician, other than your primary physician or any facility outside the affiliate network, see what are the requirements of coverage. It is better to ensure that the medical facility you are availing is a participating provider of the network and you have approval of the insurance company, prior to appointment.
Getting a referral approved by the insurance provider is important, even before making an appointment as otherwise, they can use that as grounds for not providing coverage. Same goes for any diagnostic test or surgery that you may have to undergo. Have somebody to be in close touch with the insurance provider company's help desk and get an approval from them, prior to it.
Ensure Correct Information in Claims and Billing
Many denial cases occur due to wrong information submitted in claims and billing information. Make sure that there are no errors regarding your full name, your social security number, and other billing data.
Knowing your policy details and your rights is a very important part, if you want to avoid being served a claim denial by any company. One can always make a health care denial appeal if one finds that the insurance company has been unjust. However, it is often a time-consuming battle which can be very taxing.
The best way out is to ensure that you are clear about the insurance policy guidelines, right at the start and ensure that the medical insurance claim, as well as billing information sent, provides the right information. Maintain all documentary evidence of hospitalization as well as correspondence with the insurance company, as you will need all that, in case of a denial appeal. I hope you don't have to face such a situation.