CLARIFYING INSURANCE CLAIMS What is an Insurance Claim? Often those in the scleroderma community find themselves frequenting health care providers and being left with mounds of invoices and bills. Medical invoicing while common practice for physician offices, can lead to frustration and confusion when terminology is misunderstood or misinterpreted. Understanding the components of a medical invoice can enable you to be a more effective health care advocate. Once services are rendered, an insurance claim can be submitted by a physician s office or by the policyholder. Explanation of Benefits Every time a scleroderma patient sees a primary care physician or specialist, has medical diagnostic testing or procedure screenings performed, an explanation of benefits, EOB will be provided by the insurance carrier. The explanation of benefits is a summary of services which includes costs and how much the insurance carrier will cover for the services that were rendered. The EOB will also include what your insurance carrier will not cover and how much you will owe to your health care provider. Remember, your EOB is not a bill. What s included on the EOB The explanation of benefits will generally include three sections. Financial information about the claim, this includes total billable amount, the benefit amount that has been approved by your insurance provider and the balance that will be due to the medical health care provider. Information about the medical services, this includes the date of service, the medical facility where treatment occurred, the health care provider who performed the service and the charges for the service, (billed and allowed charges). Summary, this includes, your out-of-pocket costs.
THE EXPLANATION OF BENEFITS When you receive your EOB in the mail, it is important to review all documentation in a careful manner. Errors in the contact information can occur and reviewing this information is the first step when looking at an EOB. Start with your name, address, and remaining contact information. Check to assure the dates and diagnosis or procedure coding is accurate. If you locate errors or in the event you are unclear whether there could be an error in the medical billing, it is advisable to contact your physician s office for clarification. Medical billing fraud and medical identity theft can be avoided by reviewing EOB statements and if the medical billing does not accurately reflect services, procedures or equipment, you can contact your health care carrier to discuss the discrepancy. When your health care plan denies or reduces payment of services this will be indicated on the EOB. These are explained in detail often on the back of the EOB or on the bottom of the statement. There are several common reasons for declining of payment or a reduction of payment by a health care plan. Some of these include: Being out of network and not having medical coverage or limited coverage due to the selection of a service that was provided by a physician, hospital or clinic outside of your provider s covered location. These are not contracted with your health care plan at their negotiated rate. As a consumer, you will be responsible for the balance, your coinsurance payments and deductibles. Service or procedure is not medically necessary and no documentation has been provided supporting the need. Health care coverage is not available for the specific medical procedure or equipment due to lack of medical coverage under the health care plan. Error in medical billing codes by your health care provider. This can include an incorrect code for a procedure, equipment or a diagnosis which results in a denial of benefits.
APPEALING A DENIED CLAIM How to Appeal a Denied Claim It can be frustrating after seeking medical treatment to learn that a procedure, medication or equipment is not covered by your insurance provider. Medical claims can be denied for several reasons and this is why as a consumer it is a good decision to check with your insurance carrier prior to seeking treatment to verify coverage. In the case where a medical claim has been denied, there is an appeal process available through all insurance carriers. The amount of time one has to appeal a claim has been increased to six months under the Affordable Care Act. Understanding why your claim was denied The first step to appealing a claim that your insurance provider has denied is to understand why it has been rejected for payment. The best place to seek information about your claim is your explanation of benefits, more commonly known as the EOB. The EOB is a standardized form that insurance carriers use to provide information about all claims whether they are approved for payment or denied. After review of the EOB if you continue to have questions about whether your claim was properly handled, you can always contact your insurance provider directly to seek more information. When reviewing the EOB check to make sure all of your contact information is accurate and updated. Something as simple as an incorrect entry can cause a denial in payment for your claim. If you find errors in the EOB contact the medical professional s office, hospital or clinic who submitted the claim and request a correction and resubmission of the claim. One good reason for accurate documentation of your medical visits can be found in errors on the EOB. If you keep records of every visit, procedure or purchase of medical equipment this will help you provide the necessary documentation for the insurance provider. Submitting letters of verification to your insurance provider When submitting an appeal to your insurance provider the fastest way to assure that the claim will be processed is to complete the paperwork correctly the first time. Checking with your insurance provider to learn what standard forms are needed or if a letter is acceptable will help your claim not be rejected a second time. It is also important to include contact information on every correspondence, your insurance information, claim numbers and dates of service. This is all information that will help the insurance provider reference the claim faster. Maintaining a good notetaking system will also benefit you should you need to provide additional information to your insurance provider.
The need for follow-up As a patient advocate you will need to not only maintain accurate health care records for yourself, by maintaining copies of office visits, procedures and prescriptions, you will also need to be diligent in your willingness to follow up on a regular basis to learn the status of your claim. Claims that are not regularly checked on will often sit and not be looked at, as opposed to the ones that are being questioned and telephone calls are being made on. Keep track on your phone, your personal calendar or whatever the best method is for you to assure that you will remember to stay in regular contact with your insurance provider regarding your denied claim. Messaging is important A denied claim can be frustrating and potentially costly. It can also be time consuming to work with an insurance provider who routinely provides the same answers about your claim or a need for a preapproval. When contacting your insurance provider it is best to do so when you are calm and ready to handle the situation professionally. The person on the other end of the phone is just doing his or her job and remembering this can be challenging at times. Try and maintain a positive, open-ended dialogue with the representative. Getting angry and losing patience with the representative will not solve anything and can actually delay the claim or pre-approval from being processed. Good ways to communicate are to have all of the information and documentation prepared and in front of you before making the call. Lack of proper information will delay the process. Don t make assumptions about what the representative knows or doesn t know. Rather, educate them about the claim and provide them openly all the information you can, offering to forward any necessary information to them. Have paper and a writing utensil available before you make your call. Ask the representative their name and correct spelling so you can document who you spoke to and the date you made contact. This might be needed later. Don t shy away from asking the representative how they are doing, being cordial and friendly will be helpful in setting the tone for the conversation. Remember, the person on the telephone is not the one who made the decision to deny your claim so there is no reason to become infuriated or angry with him or her. Don t delay health care treatment Waiting for your insurance provider to pre-approve your claim or to make a decision on a claim should not affect your decision to seek medically necessary treatment for your health care needs. If you are critically ill or in need of seeking medical attention your medical team of professionals can file an external appeal or you can file one. Check the Healthcare.gov website for more information about this process. What to do after the second denial If a claim is denied a second time there can be options for external reviews of claims. Check with Medicare and Medicaid and the state of Michigan to learn what policies and procedures exist. External
appeal would take the process to an independent third party. This removes your insurance provider from the appeal process and moves towards meditation. https://bucks.blogs.nytimes.com/2011/07/11/7-steps-in-appealing-a-health-insurance-denial/ https://www.nerdwallet.com/blog/health/managing-health-insurance/tips-appealing-denied-health-insuranceclaim/ https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
What is the Best Insurance Plan for You? There are different insurance options to select from based on personal needs. Individuals have the options of choosing employer plans, government funded plans and commercial plans. Employer plans If you are a person that works for a company or organization, they may offer health insurance plans. People with scleroderma have to be eligible, meeting specified criteria. Once the person is eligible, he or she must pay the specified premiums every month. A premium is an amount owed for his or her health insurance. Employers typically offer lower premiums compared to an individual plan because they offer the service to a certain amount of employees. Commercial plans Commercial insurance plans are issued by two separate sources, private companies and nongovernmental organizations. They are for-profit companies with some functioning as nonprofit organizations. As a consumer, you will pay monthly premiums for your insurance coverage and the amount will vary depending on the amount and type of coverage. If you are employed your employer may offer a commercial insurance plan that can be renewed every year. Government sponsored plans Well known examples of governmental insurance plans include but are not limited to, Medicaid, Medicare, the Veterans Health Administrative Program and the State Children s Health Insurance Program. Commonly used insurance terms you should know Health Maintenance Organization: HMOs require you to choose a primary care physician (PCP) in their network. You must see this PCP for any health issue apart from emergencies. The PCP can refer you to a specialist in the HMO s network if they cannot fully treat the issue. The exception is obstetricians/gynecologists, with whom patients can make an appointment directly. HMOs often have the lowest premiums and out-of-pocket costs, but they offer fewer choices. If you want to see a doctor outside the network, it will not be covered. The amount you pay for a monthly premium, deductible, and co-pay depends on your plan. Preferred Provider Organization: PPOs also have a network of physicians, but offer policyholders more freedom and flexibility. If you see an in-network doctor, your co-pay is lower and a larger portion of the services are covered. You still have some coverage if you see an out-of-network doctor, but a smaller portion of the cost is covered and you pay more out of pocket. If you want to see a specialist, you do not need a referral from your PCP. As with HMOs, PPOs charge monthly premiums, deductibles, and co-pays. The amounts vary depending on your policy.
Exclusive Provider Organizations: An EPO requires you to see in-network doctors, but you are not required to see a PCP for a referral before seeing a specialist. You do not receive any out-of-network coverage, so your choices are limited to in-network providers. EPO plans are less expensive than most HMO or PPO plans. They may be best suited to young, healthy individuals who do not expect to need much medical care in the coming year. You pay monthly premiums, deductibles, and co-pays. Point-of-Service Plan: A POS combines elements of HMO and PPO plans. Under a POS plan, you have a PCP who provides most services and can refer you to an in-network specialist if necessary. Many of the PCP s services may not be subject to a deductible. Like a PPO, you have the option of seeing an out-of-network doctor. You will receive some coverage, but your out-of-pocket costs will be greater. You will be charged monthly premiums, an annual deductible, and co-pays. Flexible Spending Account: Employers who offer health insurance may also add a flexible spending account as an optional supplement to the health benefits package. You elect an amount to be taken from your salary during the year, tax-free, in equal increments from each paycheck. You can use this money to pay for any eligible out-of-pocket medical and dental expenses you incur during the year, including deductibles, co-pays, over-thecounter medications, eyeglasses and other medical devices, and various health-related supplies. High-Deductible Health Plan: HDHPs charge a higher deductible than most other health plans. The threshold is defined as an annual deductible of at least $1,350 for an individual or $2,700 for a family. The monthly premiums usually are lower than a standard HMO or PPO plan. HDHPs often are paired with a health savings account to make the deductible more affordable. This option is most appropriate for healthy individuals who do not anticipate needing much healthcare and can afford to pay the large sum if a medical emergency arises. Health Savings Account: If you choose a HDHP, a health savings account is a helpful complement to it. The account allows you to put aside money to cover your deductible, copays, and other eligible health care-related expenses. As with a flexible spending account, you do not pay taxes on the funds you put in this account. Many health insurance providers that offer HDHPs also offer health savings accounts, but you can also open this type of account at most banks. Private Fee-For-Service: A PFFS is a type of Medicare Advantage (also known as Medicare Part C) plan that is administered by a private company. You can choose a PFFS only if you are enrolled in Medicare, which is available to people age 65 or older. A PFFS lets you go to in-network doctors, and doesn t require referrals to see a specialist. However, doctors can choose which services will be covered on a case-by-case basis. You can see an out-of-network doctor who accepts the plan s terms, but your out-of-pocket costs will be higher. You pay monthly Medicare premiums and any co-pays.
Learning More about Drug Tiers and Formularies A formulary is your prescription list covered by a plan. Drug Tiers help organize drugs; where it is placed in specific groups. The drug group it is in helps identify how much it will cost. Tier 1- Preferred generic brands Tier 2- Generic Tier 3- Preferred brand Tier 4- Non-preferred (higher priced drugs) Tier 5- Specialty (most expensive, drugs for cancer and other diseases) https://www.healthcare.gov/glossary/formulary/ Still need insurance terms?