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How To Beat Your Stubborn Health Insurer

How To Beat Your Stubborn Health Insurer

9 Ways To Get Your Health Insurance To Pay Your Claims.

Insurance companies have one thing on their minds and unfortunately it’s not your health”¦it’s their money. They are known for making it hard to get the money your are entitled to then they try to drag on the claim until some people simply give up.

health insurance How To Beat Your Stubborn Health Insurer

Well, fighting back against this kind of trickery-and winning-is a lot easier than you think. Now there are nationwide Health Advocate firms which help patients deal with their stubborn insurers. Advocates come at price so hiring them may only be worthwhile for larger claims. However in a recent interview Kevin Flynn, president of health care Advocates, gave some helpful advice which can help you win lesser claims on your own.

Don’t Pay If You Don’t Have A Say

Most medical plans make it clear that when you seek and out of work doctor you will be billed. But when you have surgery the hospital chooses the anesthesiologist, even in this case it is not uncommon for the insurance to hit you with an annoying “out-of-network” bill.

If this happens, you should write a strongly worded letter stating you had no say about the anesthesiologist-in-network or otherwise-and, therefore, won’t pay any additional fees.

“If you don’t have direct control, you are not liable,” Flynn says, adding that this tack is likely to work every time, but few consumers know about it.

You May Be Eligible For More Coverage

Depending on your state, you could be eligible for more benefits than your plan is telling you about. However it is very unlikely that your plan is going to bring this to attention.

For example health plans operating in Maryland must pay for expensive infertility coverage. But one state over, in Virginia, they don’t.

It’s up to you to find out exactly what you are state-mandated coverage entitles you to. One good place to check is Families USA (, a consumer group that keeps tabs on state rules. Another option is to contact your states insurance commissioner.

To Get Tested, Talk Up Your Symptoms

Your insurer does not want to pay for a treatment that is unnecessary and they will do anything they can to find a reason to reject your claim. If you are choosing a procedure for piece of mind its best to talk your symptoms up. Also find out exactly what you are covered for so you are not fighting a lost cause.

For example if your best friend is diagnosed with colon cancer and you want the $675 test to put your mind at ease you should mention to your doctor that you’ve had some blood in your stool and a lot of gas lately-or simply that your bowel habits have changed. Many medical plans will pay for the test if you have gastro complaints, health experts say. (Only 21 states require insurers to cover colonoscopies for general screening.)

A Little Research Can Go A Long Way

If you are trying to claim specialist treatments such as a CT scan or MRI, your Doctor probably won’t authorize it unless it’s an absolute must.

Try to find out as much as you can about the treatment you seek. Persuading them with expert info from the American College of Radiology’s Appropriateness Criteria is a good way to help your case. Used primarily by doctors but open to the public, it’s an up-to-date list of the types of imaging that are right for various conditions
If you want a special, your doc says Anne Roberts, executive vice chair of the department of radiology at the University of California, San Diego.

Arming yourself with the info doesn’t guarantee coverage, but if your doctor is on your side you have a better chance of getting what you want.

Stall First, Answer Questions Later

In some cases insurance companies may ask you to sign a release form allowing them to view you medical history. If this happens, do not sign. If the company can view your medical history they will looking for any info that, may have accidentally omitted on your original application. If they can find anything that has been omitted they will refuse the claim. This is actually illegal as the law says your medical record is private.

The best solution to this situation is to simply refuse to sign. The insurers review process usually lasts only 60 to 90 days, after this time they often drop the inquiry and sometimes even pay out with no further questions.

This happened to Wendy and Chris Decenzo whilst they were trying to claim funds for the birth of their child. Three months after refusing to sign the release forms the plan started paying for the prenatal appointments, even going back and paying for earlier visits that hadn’t been covered

Letters Are Your Best Bet

Writing and sending off a letter is usually more work than making a phone call or sending an email, but when your dealing with insurance companies it is the only way to communicate.

Telephones calls can be time consuming and stressful and once you’ve finished your call there is no evidence that it even happened.

Letters being more formal, nearly always get a response. Some companies will answer emails but not always. Experts recommend following your plan’s appeal process for letters and sending copies to your state insurance commissioner.

Also, keep copies of every letter you’ve sent your plan and everything they’ve sent back. This way when your insurer says, “We never said we’d cover that,” you will be able to reply, “I have it right here in writing.”

Doctors Can Be Good Weapons

If you just went for a treatment recommended by your doctor but your insurer refuses to pay, your doctor is your weapon of choice.

For example if you just had several massage sessions for back pain under doctors orders, and the insurance company still refuses to pay ask your doctor for help. He can tell the insurer he’s going to complain to the state board that regulates health plans.

“Health plans may not fear you, but they do respect the board,” says James Moss, a retired Kentucky surgeon.

You can also threaten to contact your congressman and/or state Medicare office to lodge a formal complaint. But don’t actually contact your state board yourself if a claim is denied, Janice Weiss, a Jupiter, Florida-based attorney who fights health plans for consumers, says some of her clients who went this route ended up hurting their cases when the state agency ruled their claims invalid.

There Are Ways To Get Drugs Cheaper

Doctors often marvel at the latest and greatest drugs on the market, which of course tend to be the most expensive. Sometime insurance companies won’t pay for these newer more expensive drugs or other times they may charge higher co-pays. So it’s a good idea to make sure these high-end meds are really what you need.

In most cases many drugs have generic versions that are just as effective but cheaper in cost. Always ask your doc (or the pharmacist) for generics

And if you really need a medicine that doesn’t have a generic version, order it by mail. Many plans have a less-expensive mail-order pharmacy option.
Doctors are often wowed by the latest and greatest drugs, which tend to be the most expensive. Make sure these newer,

For people who regularly need prescription due to chronic conditions like allergies. Try to ask your doctor for two or three months’ worth of medication instead of one. This will eliminate extra co-pays.

An Advocate Can Help You Win

Patient Advocates are part of a growing industry that makes money from helping you.
Some advocates help you interact with your doctor, while others specialize in insurance disputes. Most of all they keep the letters going out on your behalf, saving you time, energy, and headaches.

“The insurers know that advocates know the laws, the regulations-things a regular consumer might not know. That makes them nervous,” Flynn says.

Advocates do have weight when it comes to insurance problems and can even get policies changed. One of Flynn’s clients, who had rectal cancer, was having trouble getting his insurance plan to pay for a new radiation therapy. The insurer claimed the treatment wasn’t ready for prime time, but Flynn found six studies showing its usefulness for the disease, got the coverage-and got the insurer to rewrite its policy.

To find an advocate, contact the Patient Advocate Foundation. Another helpful resource is the Society for Healthcare Consumer Advocacy. You could also try checking with the medical association for a particular condition, like the Multiple Myeloma Association or the National Association of Anorexia Nervosa and Associated Disorders; many of these groups keep lists of advocates.


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