Wednesday, 27 January 2021
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Health insurance knowledge

As a customer of Family Assurance Centre, rest assured you have the expertise of our company standing by to assist you. We want your claims experience to be a positive one, and you are completely satisfied!

However here are some tips to help avoid denials of coverage by your health care provider:

Information is power, and this is never truer than when battling a health care system. The winner may be the side with the better-organized, more-detailed information.
The best bet when dealing with insurers is to minimize the risk of denial, and then if one does come your way, to solve the problem in the early stages.
Here are some steps to help avoid denials of coverage by your health care provider before they occur.

  • Understand your policy thoroughly. Review it on a regular basis, and ensure that you know exactly what is covered and what isn't. If you have questions or don't understand any aspect of your coverage, call your insurance company and make them explain it in layman's terms. Make sure you understand the exclusions and limitations of the policy, and the section on how to appeal.
  • When receiving medical care, make sure your health care provider understands what is covered and what is not. Remember, doctors deal with many patients and many insurance companies. Don't assume they all remember the particulars of your situation.
  • Take your policy provisions seriously. If it dictates that prior authorization is required, then don't receive care without obtaining that authorization. Assuming that the company will cover you and you can obtain coverage later, even if that is what your doctor tells you, could lead you into a world of bureaucratic hell, and might lead to a denial of coverage.
  • Keep detailed notes! This cannot be overstated. Take notes of every aspect of the process -- when you received authorization and from whom, the day you received treatment, what you discussed with your doctor, what action was taken and what follow-up is required. Every phone call made, person spoken to and action taken needs to be documented, including all names, dates and places.
  • Save copies of all paperwork from your doctor and your insurance company. Keep these records in chronological order for easy location.
  • If using an out-of-network provider, establish before care is provided that they will accept your health insurer's payment in full.
  • If there is a claim for which your insurance company will reimburse you only after you've paid your provider out of pocket, be sure to file the claim immediately.

When prevention fails
Assuming you have taken all these steps and are still denied coverage, do the following:

  • Review all the paperwork regarding the case immediately, making sure you understand every aspect. Then, with your paperwork in front of you, call your insurance company. Use the customer service number.
  • The insurance company rep should be able to tell you why you were denied coverage. Make sure you take detailed notes of the conversation!
  • Denial of coverage is often a result of administrative error. If this is the case, you may be able to resolve it on the first call, or with just some minor communication thereafter.
  • Assuming the problem continues, request an itemized bill from the doctor or hospital, and analyze every charge. There are often charges on these bills for services not delivered. If you find any, notify the doctor or hospital immediately to get the bill adjusted. Then, notify your insurer.

Often, however, the denial has been legitimately issued. The insurance company may not consider your medical procedure necessary, may consider it experimental or outside their coverage area. That being the case, it's time to take additional steps.

  • Request a formal review by the insurance company. The customer service rep can tell you the specific procedures required. Then, state your case for appeal in writing, and send the letter via certified mail with return receipt requested. Make sure to do this immediately. Some companies have time limits on when appeal requests can be filed. Don't wait.
  • If the insurance company claims that the cost of your care was above their customary cost, request the doctor's or surgeon's notes. They may show that there were mitigating circumstances in your case that justify that cost. Also, request any other information you need from your doctor to prove your case, and make sure you have it all in writing.

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