Insurance explanations of benefits can often be difficult to decipher, and it can be frustrating to open an envelope and find only a piece of paper when you were expecting a check. While insurance companies can make mistakes, there are plenty of things you can do to minimize the chances of claims being rejected when they should be processed.
Use the correct ID card
The health insurance environment has been tumultuous, to say the least, over the past few years. Many businesses have found it necessary to change insurance carriers frequently in an effort to continue to provide their employees with good coverage at a reasonable cost. Make sure you put the new ID card in your wallet immediately, and take the old ID cards out and put them in your medical file at home. You may wish to save the old ID cards for future reference should you need to go back to a previous carrier for a claim problem, but having just the current ID card in your wallet will certainly cut down on confusion and errors when you need medical attention. Claims submitted to the carrier which is no longer active will definitely slow down the process for you. Receiving medical attention can also be hindered if the office calls to pre-certify something and is told the plan has terminated.
While we are on the subject of ID cards, keep in mind that if both parents have separate plans, know whose plan is primary for the children. There are many husband/wife small groups and benefits are written for one parent being a parent/child contract and the other parent having a single contract. Make sure you use the ID card for parent / child when you take the kids to the doctor. Likewise, if you and your spouse are both covered under the same small group plan but have separate contracts (you both work for the same company or are self employed together) make sure you use your ID card and not your spouses. Claims submitted under the wrong card will be declined even if the group number is the same. The group number, ID number, and patient must all match.
Get pre-certification for hospital admissions and other services that require it.
Failure to do so can result in claim payments being reduced by a few hundred dollars, or even up to 50% of the amount billed. The process to pre-certify a hospital stay or medical procedure is really quite simple: you pick up the phone and speak with a customer service person at the insurance company. Know what services need to be pre-certified and make the call! If you are not sure whether something needs to be pre-certified or not call your insurance company. Make sure you jot down who you spoke with and ask for their first and last names. Make notes of what they told you, and if the service does require pre-certification, they should give you a confirmation or reference number. Keep that in a safe place with your medical claims. You may need to refer back to it if there are problems with the claim later on.
Student status / Other coverage inquiries
Dependent children who are enrolled as full time students can continue coverage under their parents plan for a few years past when they would have otherwise been taken off the plan. The insurance companies do need proof of student status though, and submitting this in a pro-active fashion will prevent claims from being denied or suspended while it is obtained. In other words, after you have recovered from getting junior or junior-ette off to college, call the registrar’s office for a letter substantiating full time student status. If you have a good benefits administrator or insurance agent, that person should be able to submit and follow up on it for you. If not, call the insurance company and get instructions for submitting it to them. Some carriers accept faxed copies, while others require sealed original letters complete with the college seal. Keep in mind this must be submitted each semester.
You may receive a questionnaire from your insurer asking if there is other coverage. People are often confused by this and wonder why their insurer would think they have other coverage. It is simply a routine matter of computer generated letters going out to check in and see if your insurance situation has changed since the last time they inquired. If you do not have other coverage, simply state that and return the form. Claims can be suspended until this information is received, so don’t put it in the pile of paperwork to deal with when you get bored. Many insurance companies are becoming internet friendly and you may be able to log onto your carrier site and update this information electronically.
Deductibles / Denials
Watch the column that says “deductible”. If you need to satisfy a deductible before benefits are paid, keep in mind that if money was put towards your deductible, it is not that the claim is being denied, it is just that you had to meet that deductible first. This is an easy area for mistakes though, and we advise that you keep tabs on what your deductible is, and how much has been applied towards it. If you find that you have a $250 deductible, and $500 has been applied to it, you should call the insurer and ask them to please correct that immediately. Most deductibles run accordingly to a calendar year.
If you don’t understand something – ask
Finally, if you do receive an explanation of benefits that you simply do not understand, or no payment is granted where you thought it should have been, call the insurance company and ask them to explain the claim to you. Perhaps an error has been made and the claims analyst you speak to can correct the problem right then and there. Perhaps they simply needed more information: a diagnostic code, a proper date of service, or whether there is other family coverage.
Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance Claims, Inc. a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.
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