Stuck with a Confusing Health Care Situation? Here's What to Do

Having health insurance is one of the best decisions a person can make for their overall health and well-being. It assists in avoiding high medical costs, provides access to a number of free preventive health services and even contributes to a more productive career. Still, there are times when health insurance might seem complicated—like when there’s confusion over whether or not a service is covered or if the right amount is being charged. No matter what unclear situation arises, there are ways to effectively resolve the issue:

Scenario #1: You’ve been denied for a procedure that’s normally covered.

Say you recently visited the doctor’s office for your annual exam and, unexpectedly, receive a letter denying coverage for your visit. This could have been caused by a number of factors, including the use of the wrong billing code when processing your services.

Not only do you have the right to appeal this decision, but you should request an explanation of denial from your insurer. Before calling the number on the back of your member card, gather pertinent documents including your denial letter and Explanation of Benefits. During the call, be sure to take notes and write down the names of any representatives you speak with.

If the denial is upheld, submit a thorough, detailed letter to your insurer (this form can help) about why the decision should be reconsidered. Talk about the necessity of the procedure and include any supporting documents such as medical records, doctor’s notes or x-rays.

Lastly, to avoid paying potentially unnecessary costs, hold off on paying the bill until the situation is resolved with your insurer and you are fully aware of the costs you have incurred. To avoid instances like this in the future, call the number on the back of your insurance ID card to confirm that the procedure you’re planning to receive is covered.

Scenario #2: You’ve been denied coverage for a prescription your doctor ordered.

There are some instances where insurers will not cover a prescribed medication if it’s not deemed medically necessary or if there are alternative drugs that will work just as well. In cases like this, first contact your doctor to confirm that there are no other options available that can be covered by the insurer. If not, the doctor can request an exception on your behalf if they believe that other options will not be as effective.

If your insurance company still denies coverage, submit a letter of appeal containing:

  • Your personal information (including name, address, phone number)
  • Date you need to have the prescription filled on
  • Name, address and phone number of the pharmacy where you took your prescription
  • Name, address and phone number of the doctor who wrote your prescription
  • A copy of the receipt if you already paid for the prescription or a copy of the prescription if no payment was made

Scenario #3: You were charged the wrong copay.

It’s common to be asked to pay a designated copay amount at the doctor’s office during check-out, but there may be a time when you think the amount requested is incorrect. Maybe you were charged a copay for a preventive visit that is covered by your plan. Or perhaps you were charged the specialist copay when you were seeing a family doctor. In these situations, it’s best to pay the amount asked and hold on to a copy of your receipt. Then, contact your insurance company and confirm what you should have actually been charged.

If your insurer confirms that you paid too much, call the doctor’s office and speak to someone in billing. You should get reimbursed for the extra money paid. In some cases, even though you think the amount is incorrect, it is not. For instance, if you went in for a preventive annual visit, but added on a procedure, you’d still be charged a copay.

Visit these blogs to grow your knowledge and understanding of your health insurance coverage:

 

Photo Credit: Oregon Department of Transportation

Leave a Comment

Your email address will not be published. Required fields are marked *