Insurance Broker and Agent NegligenceHealth insurance, also known as health coverage, can pay for some or all of your health services bills such as hospital stays, doctors’ appointments, as well as a visit to the emergency room. Health insurance can protect you from paying the full cost of your treatment when you are sick or injured. Thus, it can help you keep your healthcare costs both affordable and predictable. However, just like a home or car insurance, it is important that you choose a health insurance plan that suits your health care needs.Too often errors in the insurance denial stems from the actual insurance broker or agent being negligent in paperwork or selling an incorrect plan for their client’s needs. Stop Insurance Denial Law Firm are here to help in these situations by fighting for the rights you deserve and against the corporate powerhouse that employs these inept insurance agents and brokers.
The Different Types of Health Insurance
Health insurance comes in various forms. You can purchase obtain this insurance through your employer, a private insurer, or through the government –popularly known as public health insurance. Some types of health insurance covers more than just medical services, and you may have to sign up for additional plans to fully cover your needs. These may include:
Why is Health Insurance Important?
If you are one of the nearly 50 million uninsured Americans, you are probably wondering why you should get health insurance, especially if you still feel young and healthy. Well, there are smart money saving tips, but skipping out on health insurance is never one of them. According to studies, uninsured folks never receive the same amount or quality of preventive care that those with insurance enjoy. Obviously, this is a huge financial risk.
1. Insurance may seem expensive, but not having one will cost you much more
You probably know someone with a heart condition, or who has had a stroke or heart attack. Now, do you know what it costs to have an open heart surgery? Well, Investopedia puts it at around at well over $300,000. Now imagine having this in your monthly bills. Clearly, health insurance can make this cost manageable for you.
2. Being uninsured affects pretty much everyone
Statistically, folks who do not have any health cover tend to wait until their condition has worsened before they can be rushed into the emergency room. This translates into huge bills from doctors and facilities that often go unsettled. To recoup lost funds, medical facilities are often compelled to charge more for their services for everyone who seeks their services.
3. Preventive care
Folks with health insurance are much more likely to use it for routine diagnostic tests and check-ups that can detect serious medical conditions early enough when they are still treatable. According to studies, folks with health insurance are physically and mentally healthier.
4. Transitioning to a new job
The number of people seeking college education after staying out of high school for years is on the rise. Most universities and colleges are making health insurance a mandatory requirement during admission. In fact, some institutions even require prospective students to have specific covers.
You purchase insurance for your home, car, and other material stuff, so why would you not secure your health too? Of course, home and car repairs can be costly, but have you thought about how much it would cost to fix YOU if there is need?
Grounds for Health Insurance Denial
Getting your health insurance claim rejected is enough reason to get you sick all over again –especially if you are dealing with a huge medical bill. The good news, however, is that your insurer owes you an explanation, which usually comes in the form of Explanation of Benefits (EOBs). The EOB comes with abbreviations and codes that explain what the cover will pay or why your claim has been declined. Most health insurers provide a guide to help you interpret the codes on your EOB.However, this often does not answer all questions. That said, here are top reasons why your insurance company might decline your claim:
1. You are making non-covered claims
It is possible that you have been treated for a condition that is not covered by your health insurance policy even if you feel it should be covered. Take a closer look at the policy’s terms and conditions. Some plans do not cover certain care, like cosmetic procedures, dental surgery, or fertility treatments. If you feel you will need care that is not covered by your current policy, consider shopping for a new policy.
2. Where a referral or pre-authorization was required.
Procedures like MRIs and CT scans require pre-authorization, which should be requested on behalf of the patient by the doctor. Some providers will, in fact, turn you away if you do not have an authorization. If your claim has been declined even after your doctor’s authorization request, ensure that you get your doctor to contact the insurance company for explanation.
3.When you use an out-of-network provider
Your claim can be declined if you go outside of the plan’s provider network for treatment. This is especially true if your carrier is an exclusive provider organization or a health maintenance organization. Going out of an EPO or HMO network means you are seeking treatment from a provider who has not agreed to your health insurance provider’s payment terms. Your carrier may thus decline your claim or demand that you meet part of the cost if you receive non-emergency or elective treatment from a facility that does not have any out-of-network benefits.
4. When there are transaction errors
Has your name been wrongly spelled? Does birth date indicate that you were born in 1998 instead of 1989? If you cannot figure out whyyour claim was declined, look out for the typos. Claims easily get turned down on grounds of minor data entry errors. You can solve this by contacting the customer service representative to help you resolve the data error.
5. The bill ended up at the wrong insurance provider
This should be straightforward. Have your doctor’s office billed the wrong carrier? Is your policy active? If you are seeing a carrier you have not done business with in a while, chances are there is an outdated insurance information on your file. Your claim can also be denied if you have two active policies. For instance, there can be a billing problem if you have coverage through your employer as well as through your spouse’s employer. You need to double-check that your provider has updated information well before you make your claims.
How to Avoid Health Insurance Denials
Whether you are sticking with your current health insurance cover or shopping for a new one, you might run into trouble making claims after your treatment. Though you cannot prevent all possible errors affecting your claim, there are precautions that you can take to reduce the chance that the insurer will turn down your claim. Here are six steps you can take to avoid health insurance denials.
1. Double check to ensurethat you provide accurate information on your claims form
This includes ensuring that the name is spelt right, your subscriber number is accurate, and the name of the guarantor too is correct. Other information you should double-check include your date ofbirth as well as your service date.
2. Ensure that you have listed the correct diagnostic or procedure code
Payer processing system will decline records that are inaccurate, incomplete, irrelevant, or are not covered by the policy. If your claim is declined, find out whether the rejection has something to do with an incomplete or inaccurate code and alert the billing department.
3. Always get preauthorization
Your health insurance provider may require that your doctor submit a request for preauthorization detailing why you need to undergo a specific medical procedure. This is an increasingly common requirement especially where tests, certain medications, and even treatment procedures are involved. Always inquire beforehand whether the procedure or medication requires a preauthorization and whether your planned hospital stay is approved.
4. Understand the benefits if you have more than one plan
The insurer may decline your claim if it has reason to believe the order in which you have submitted it is incorrect. Find out whether your plan is primary or secondary. For instance, if you are working but are also on Medicare, your employer’s plan becomes the primary if your organization has 20 employees or more. However, it becomes secondary if your organization has fewer than 20 employees. When you and your spouse are covered by two or more policies, be sure to inquire about the coordination benefits rules from both carriers before submitting your claim.
5. Understand state laws
Your claim may be rejected in some states if it is due to a work-related accident or a car accident. In such cases, you will need to make your claim to the worker’s compensation or automobile (no fault) carrier. Here too, you claim may be declined if a third party is responsible, such as the store where you fell on a slippery floor. Here, your claim is to be covered under the store’s liability policy
6. Do not fret when your bill arrives anyway
When you receive treatment from a doctor or a hospital that has no contractor with your carrier, youwill be required to pay the difference between the amount settled by your plan and what the provider has quoted. Therefore, be sure your doctor or health care provider is in your network. This is especially important when you are receiving services from amedical facility where different departments do not accept the same plan.
What You Need to Do When Your Insurance Claim Has Been Denied
When you need medical attention, the last thing you want to worry about is whether policy will pay for the treatment. Unfortunately, your medical claim can be denied for some of the reasons already mentioned above. Luckily, you can get your carrier to reverse this decision. Your right to appeal a rejected medical claim is clearly articulated under the Affordable Care Act. That said, the following tips can help you optimize your chances for a successful appeal
1. Understand why your claim was declined in the first place
Before contesting a rejected claim, you need to understand the grounds upon which it was declined. Your Explanation of Benefits (EOB), a standardized form provided by the carrier whenever a claim is cleared or rejected, uses codes that explain how the insurer arrived at the decision. Most EOBs also come with a key to the codes to make it easy for you to understand what everything means. If it is still not clear why the claim was rejected, call the insurance company and ask why. You have the right to be informed, and the insurance company is under obligation to explain everything in a language that you can understand.
2. Take care of easy problems first
Sometimes, as already mentioned, your claim can be rejected on grounds of simple data-entry errors like an inaccurate insurance ID number, misspelled name, or wrong service date. Carefully read through all the documentation provided by your insurer as you look out for errors. Ask the insurance to correct any error identified on the spot. If the error originated from the medical provider, be sure to ask them to correct it before resubmitting the claim.
3. Put together your evidence
Be sure to put together all the evidence indicating that the service for which you are seeking acclaim was medically necessary. A referral, your doctor’s prescriptions, and information about your medical history can help get your claim accepted the second time around. You may also ask your doctor to reference your plan’s medical guideline or policy bulletin for the received treatment. This information should be available through your insurer’s website.
4. Submit the right paperwork
You may have to write a letter to your insurer. If it gets to this, be sure to include your claim number as well as the number on your policy’s card. Your appeal may be resolved faster if you use your insurer’s standard appeals form. The EOB should guide you onhow to submit an appeal, or you may contact a claims lawyer to take you through the appeal process.
5. Be organized
Every insurance company has its own internal mechanism for tracking subscribers’ medical claims as well as appeals. As a client, you too have to be just as organized to be certain that you are following up on any details that might make the difference. Keep your paperwork organized and pay keen attention every time you are in communication with your insurer. Note down the name and the job title of the agent you are on phone with and write down the conversation date as well as any agreements you arrive at during the conversation. This information will help you build your case and move your appeal process forward
6. Pay attention to the timeline
It is not unusual to call your insurer once and then forget about following up. You need to put in place a system that will help you with the follow up. If your customer care agent promises to resubmit your claim and that it might take a week before you can get a feedback, take note of this and check on the status of your claim after one week.
7. Do not shoot the messenger
Having a claim rejected can be scary. It gets worse when you have to wait for a pre-approval before going for a test or a procedure. But always keep in mind that the customer care agent on the other end of the phone is not the one responsible for rejecting your claim. Turn them into a valuable ally by treating them with respect and courtesy. If you find yourself getting frustrated, explain to them that you are getting concerned about your case but you understand that they may not be at fault.
8. Take it a notch higher
Until now, you have been handling the appeal directly with your insurer. But if your claim is rejected the second time, you may have one more chance to turn things around. This is where your state’s insurance board comes in. Filing a complaint with your state’s insurance board will automatically a review of your rejected claim, the efforts you have made to have it reversed as well as your evidence and reasons for appeal. The state’s insurance commissioner will review your complaint based on its set rubric and request for a response from your carrier.
Finding an Insurance Broker and Agent Negligence Attorney Near Me
If your insurance company has sent you a Reservation of Right letter or is demanding for an Examination Under Oath (EUO), it is time to get professional advice. These letters are often a telltale signs that things are about to turn ugly. A health insurance attorney will review your coverage to determine whether your claim should be covered by your policy. Most health insurance attorneys such as us will review your claim for free. If they find that they can help you, then they will proceed to work on documenting the justification for your claim, contacting the insurance company on your behalf, taking legal actions if necessary, and maximizing your medical claim settlement.
Health insurance policy is meant to pay for your medical care when you need medical care. However, if your carrier has rejected your claim, or is not paying for enough of the claim,due to incorrect filings or plans that your insurance broker set up for youthen you may want to press charges. Stop Insurance Denial Law Firm has a team of experienced attorneys that can adequately represent you and ensure that you get what you deserve. Headquartered in Los Angles, Stop Insurance Denial Law Firm represents clients throughout the United States. Call on 310-878-1771 and speak to one of our customer care agents today.