By Marc Manor
Those of us old enough to remember “Gomer Pyle”, can visualize
the scowl on Sergeant Carter’s face when Gomer revealed his many
surprises! Surprises can be great but
not when it comes to healthcare insurance claims, most of us want to our bills
to be exactly what we expect – NO SURPRISES!
Healthcare insurance claims are based on a long list of
medical codes that are associated with each treatment, diagnosis, and/or
medical procedure. The codes are
entered by medical data entry people to base them on a patient’s chart or
doctors notes. The codes have a variety
of uses in the medical field but the codes that are probably most important to
us as healthcare insurance beneficiaries are the ones correlated to our
healthcare benefits. The codes submitted
to the insurance company will determine how claims will be processed. Allow me to provide you with some examples
that may help in understanding how the codes affect healthcare insurance
claims:
“I received a bill for a recent lab test. I thought lab tests associated with qualified
preventive care was 100% covered!”
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Alice may have been able to prevent this claim from being
submitted as a diagnosis if she would have made the appointment for a wellness
exam; however, sometimes doctors only allow certain time slots for wellness
exams and they require setting the appointments long in advance. If this was the case, Alice would not want to
delay her diagnosis if she was in pain or otherwise suspected she had a serious
problem. If she had not had her wellness
exam that year, she may have been able to talk to her doctor about coding as
such, but that would be at the discretion of the doctor. Some doctors actually farm out their wellness
exams to subordinate staff or outsourced altogether.
My advice is scheduling that annual wellness exam every year
during your birth month. Some healthcare
providers will do this automatically, so ask about it; but, never hesitate to
call your doctor if you are in pain or you suspect something is not right. A co-pay or co-insurance is
“My insurance company did not cover ambulance transportation”
Had this come up a couple of times. We can go with “Barbara” this time. Barbara experienced a health emergency and
was transported to the nearest hospital.
Her plan covered the emergency and associated ambulance ride. Because her hospital was “out of network”,
once she was stable, she needed to be transported to an “in network” hospital
for continued care. Her ambulance
transport was medically necessary; however, the private ambulance company
provided an incorrect zip code with the insurance claim. Barbara and her family had to make numerous
phone calls to uncover the mistake but once found, they were able to
successfully appeal the claim and the insurance company paid the claim.
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“Charley” was transported home from a hospital stay by
ambulance. The transport was medically
necessary because of Charley’s condition but the claim was not paid by the
insurance company because of a mistake in the coding. When Charley received the bill from the
ambulance company, being an upstanding citizen, he paid his bill. I would never advise someone not to pay their
bills but if you think something is amiss, I recommend looking into it first
then pay once all requests and/or appeals have been exhausted. In this case, Charley had a valid claim but
had an extremely difficult time with the private ambulance company. It seemed once they had their money, they
were not motivated to refile the claim with the insurance company. The “lack of motivation” on the part of the
ambulance company made them very difficult to deal with.
So, what can you do?
-
Talk to your providers at time of service if
possible. This is the best way to avoid
problems in the first place.
-
Discuss these types of situations with your
loved ones so they can ask for you if required (see my blog about Authorized
Representatives).
-
When coding mistakes or other billings seem
incorrect it is generally best to reach out to Member Services and/or your
agent.
o
Most healthcare insurance companies provide
their Member Services number on the ID card for the member’s convenience. Customer service is a high priority with most
companies, so they generally will help as much as they can.
o
You agent may be easier to contact. He or she may be able to answer your
questions without having to call Member Services.
-
File an appeal.
Healthcare insurance companies have an appeal process that allows you to
file your grievance and have your case heard at a higher level. You can use this process after exhausting
your attempts to resolve your situation.
Marc Manor is a
30-year military veteran who is now dedicated
to teaching his fellow Americans how to make the most of their Medicare and
healthcare benefits. As an independent agent, Marc has access to a wide
variety of carriers with an abundance of resources to find tailored solutions.
There is no charge for a consultation so call 904-222-0698 or visit
www.manormedisource.com today to stay on course with Medicare education and
insurance solutions.
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