Can health insurance be denied for a pre-existing condition?

Can health insurance companies deny coverage for a pre-existing condition?

According to the current laws, an insurance company cannot deny coverage for a pre-existing condition (with one exception). However, those laws are under tremendous controversy and could change at some point in the future. Pre-existing conditions is one of the factors at issue, so we will have to wait and see what happens going forward.

The one exception noted above is AARP MediGap plans. These are the plans that people over 65 buy as supplemental to their Medicare coverage. AARP has a look-back period of 3 months that is in effect for the first 6 months of their plans. This means that they can deny a claim within the first 6 months of the AARP policy, if the patient is treated for a condition that is billed with a diagnosis that had been treated within the 3 months prior to the start of their policy. AARP considers such a diagnosis a pre-existing condition. They won’t deny all claims, only those that are coded with the pre-existing diagnosis during this look-back period.

 


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If you see an out of network provider, are you stuck with the medical bill?

What no one tells you about out-of-network bills

Well, it depends on a few factors.

If you choose to see a medical provider in his/her office and that provider is not in your network, then you are considered a self-pay patient and you are responsible for the bill. It is the patient’s responsibility to know what providers are in their network, so if you see an out-of-network provider you pay the costs.

“Physician went out of network. Now I have a bill to pay”

Be aware that should you see an in-network provider, and that provider utilizes the services of a lab that’s out-of-network, you could be responsible for those charges. Determining in advance which labs are in your network and requesting that your doctor use those in-network facilities could save you a lot of time and money.

How to negotiate out of network medical bill

If your plan offers out-of-network benefits, the charges for any out-of-network services can be presented to your insurance company for payment. However the insurance company determines the allowed amounts for those charges and usually there will be a deductible to satisfy before the insurance will pay anything for the services. Keep in mind that the “charged” amount is NOT necessarily the same as the “allowed” amount. And it is only the “allowed” amount that is the amount that would be considered.

How to handle out of network medical bill

If you visit a hospital emergency room, and the hospital is in network, there is a possibility that the doctor overseeing your care is not in-network with your plan. That’s because many hospitals outsource the physician staffing of the ER. That means that the company that employs those doctors is responsible for the networks they participate in, not the hospital. You need to pay very close attention to these charges because accurate processing and payment of them often requires repeated and time-consuming conversations and follow up with your insurance company in order to have them paid appropriately. There is often an argument to be made to have the out-of-network charges covered as in-network but the determination is not automatic and requires considerable advocacy on behalf of the patient.

You may soon be protected from those surprise out-of-network bills

In some states, there is a law to help with these types of overcharges. It’s called the Surprise Medical Bill law and it states that if you enter the hospital and are seen by an out-of-network provider, that provider must provide you with advance notification of their being out-of-network and you must sign a document stating you have been made aware of this. If neither of these actions occur, you are not responsible to pay the charges. The charges, in essence, are considered “surprise” bills.

Hire a medical bill claims advocate to simplify the process

In any case, thorough review of the charges could uncover billing errors that could reduce your financial responsibility. In these instances, it could be a good idea to enlist the services of a medical claims advocate who would be well-equipped to handle the matter and ensure the accuracy of the charges. Advocates are also usually adept at negotiating reductions in fees even when the charges are correct.

For more information on the validity of medical bills, reach out to us for more details on how to control these types of medical costs.


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What to do when an Insurance Company Denise a Claim for a Hospital Stay

What to do if my insurance company denies a hospital claim

If your insurance company denies a hospital claim, the first step is to contact your insurance company and ask for clarification. Your next step will depend upon their reason for denial. They should address any fees that you are responsible to pay related to copays and deductibles. Beyond these fees, perhaps the denial requires the hospital to respond: this could involve their correcting a claim that was initially billed in error, or it could involve their appealing the denial. Whatever the reason, you should follow up with a call to the hospital to see if they plan to respond to the denial in any way. During this conversation, the hospital should inform you if there are any other issues that might require your assistance to resolve.

What to do if a hospital bills me directly

If you receive a bill from the hospital, it usually signals that the hospital has done everything it can to resolve the issues that stand in the way of payment, and they have no recourse but to bill you directly. If you don’t believe you should be responsible for the balance billed to you, or if the resolution is not straight-forward, you need to begin a thorough forensic review and accounting of the charges and the processing of those claims.

How to lower a hospital bill and get a discount

First, request a detailed bill from the hospital, one that includes each charge listed by line item, code, billed fee, allowed fee, balances and the reasons for the balances. In order to properly determine if the coding is correct, you need to request all of your medical records. It is at this point that you might need to enlist the services of a medical claims advocate, someone with experience translating documented notes into appropriate procedure codes. Since each procedure code is associated with a specific fee, if the incorrect codes were billed, your bill could reflect services that you never received.

Hospital bills are often extensive, confusing, and time-consuming. Getting to the bottom of the bill could require the help of experts. If this is a situation in which you find yourself, you don’t have to go it alone. Reach out to us for further clarification and assistance.


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IS A DOCTOR’S OFFICE OR MEDICAL FACILITY ENTITLED TO YOUR SOCIAL SECURITY NUMBER?

Am I required to give my social security number to my doctor?

The answer to this is NO.

While it is helpful for providers and facilities to have your social security number, it is not something that they need for billing purposes. Insurance companies identify you by the number they supply as your identification number, along with your date of birth and address.

Why do doctors ask for social security number?

At one time, all health insurance ID numbers were social security numbers, but that changed many years ago as private health insurance companies abandoned this practice in response to the rise in identity theft. In fact, currently only Medicare uses your social security number as your ID, and that practice is rapidly coming to an end. By 2019, Medicare must begin issuing Medicare cards with new non-social security number identifiers.

What To Do If Your Doctor Asks For Your Social Security Number

When registering at a hospital, lab, medical facility, or doctor’s office, DO NOT provide your social security number, even when it is listed as a question on the in-take forms. Many facilities still ask the question hoping that patients will provide the response. But the item should be left blank to protect you. If pressured for the answer by a staff member, simply inform them that your social security number is not required for billing or clinical purposes. If necessary, ask to speak to a supervisor who should be well aware of this.

Why you shouldn’t give your doctor your Social Security number

Medical providers have access to a significant amount of personal information that, in the wrong hands, could compromise your identity and your credit. Most of this is needed in order for you to receive care. However, they aren’t entitled to everything. Withholding social security information is your right and it is one way for you to help protect yourself against identity theft.


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WHY DOESN’T MY DOCTOR KNOW WHAT MY INSURANCE COVERS?

How do I know if my doctor is in network?

You go out of your way to ensure that any doctor you see is in your network. You pay your copay before you even see the doctor. Why, then, do you end up receiving bills that you weren’t expecting for services not covered by your insurance? Why doesn’t your doctor inform you that he/she will be performing tests that might not be covered by your policy?

Understanding what your Health Insurance Plan covers

The short answer is that even as an in-network provider, your doctor does not know exactly what your insurance will or won’t cover until the claim has been submitted to your insurance and it has been processed. While it would seem only right that all services provided by an in-network should be covered by your policy, it isn’t as straightforward as that.

Understanding your health coverage policy

In reality, each insurance company has tens if not hundreds of policies that it makes available to individuals as well as businesses. Each one is priced according to the covered benefits. Typically the more services that are covered in a plan, the higher the premium. But even within highly comprehensive policies, there is a growing list of non-covered services. These could be immunizations, tests, and certain procedures that the insurer will not cover as part of the policy. Or the insurer could limit coverage for certain services to particular diagnoses or age of the patient: these services, therefore, could be covered in some instances and denied in others.

Why isn’t my insurance covering anything?

Given the breadth of options for coverage, it is virtually impossible for a doctor to know definitely if a particular service will or won’t be covered under your policy. Insurance companies will not provide that information to a doctor in advance of providing the service and submitting the claim. However, they will supply that information to the member in advance of receiving these services.

What are procedure codes and diagnosis codes?

It is in your best interest to ask your doctor, in advance of care, what procedure and diagnosis codes he/she will be billing for services provided to you. Contact your insurance company and explain which doctor will provide the services and ask them to review the codes against your policy benefits to let you know what, if anything, you will be your financially responsible to pay. They will be able to determine not only which codes won’t be covered, but also, what codes that are covered might be subject to a deductible, requiring a payment from you.

Patients are ultimately responsible to know and understand the benefits of your health insurance.w


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