Article Contributed on: 10/29/2009 5:21:36 PM
Whether you're a democrat or republican, a small business owner or corporate executive, you want to know that your health insurance plan will support you during a health crisis. Period. Bottom line. No gray areas. Just black and white please. As a consumer of health insurance benefits, you want the certainty that the insurance premium dollars you pay out every month, the hard-earned money you spend, is going to translate to financial support in the emergency room or doctor's visit.
In last week's blog I promised you information that would help you become a better health insurance consumer and advocate. I promised to provide important information nuggets related to the relationship with your insurer, your doctor's office as well as the state and federal government's role in protecting your rights as a consumer. Exciting stuff, huh?
No, of course not. It's boring. But what's exciting is that if you've ever had issues with getting services pre-authorized, claims paid or ended up footing a bill that you didn't expect to be responsible for, there is help and assistance.
So, let's get started. There is a lot of information to cover, so please bear with me. First item on this blog agenda is the summary of benefits information that you receive from your insurance company after you sign up for a plan or renew. Some or most of you may be aware that there is such a thing that exists. Some of you may have even glanced at this summary a few times, just picking up a few pertinent details such as deductibles, co-pays and coinsurance responsibilities, the additional money spent out of pocket after your monthly premiums. A few of you may have looked carefully at a handful of details based on current health needs, such as costs for prescriptions related to certain chronic conditions. And only a courageous (or meticulous) few have dared to read the rest, including the information that relates to legal timelines for claims processing, your appeal rights when claims are denied and other sundry legal details.
Oh, but wait. You DID read your summary of benefits and you didn't notice any talk of legal stuff like appeal rights. And most likely you're right. The summary of benefits packet you receive when you first sign up for a plan does not necessarily include all aspects of coverage detail. Actually, there is yet another, more comprehensive 'summary' that lists everything you would ever need to know about your plan. Depending on what type of plan you have, it may be called 'Summary Plan Description' or 'Evidence of Coverage' or simply 'Benefits Summary'. This comprehensive description of your health plan is what I'd like you to get your hands on, and what we'll be discussing for a bit.
This comprehensive document is SO important for helping you if you ever get into a claim denial dilemma or financial pickle. I can't stress this enough. And, every detail in your comprehensive benefits description must be read. Let me repeat this. Every detail MUST BE READ! Please folks. Reviewing this important document can possibly save you a great deal of headache in the future. Having a working knowledge of this information along with your explanation of benefits (we'll talk about this important document in another post) will arm you sufficiently to take on the potential usurpers of your hard-earned dollars and mental energy. Trust me on this one.
If you have this document filed away somewhere, take a moment to retrieve it. Then, inhale a nice, calming breath. I'm going to start out with an overview of what's in this document and why:
1. For every available health service out there, the document lists what is covered, partially covered, or not at all covered by insurance company, and what your financial responsibility is - copays, deductibles and coinsurances.
Why is this important? Many reasons, but a very important one I'll list here is that mistakes are made on a regular basis. Too many times the wrong information or lack of ALL the details about coverage are provided by an insurance service representative to a medical biller calling about your coverage details. Also, a medical biller can make the mistake of interpreting the information incorrectly, or worse, make mistakes on proper coding. Even after meticulous and painstaking learning of billing and coding procedures I have made mistakes which have caused me to backtrack through a process of correction and appeals that can take many months to a year. How does this affect you personally? Remember the bill you got from the doctor or hospital that made your heart skip a few beats when you noticed the total amount due column? Yes, that's what I'm talking about.
Additionally, even though your comprehensive document states that a certain service is covered this DOES NOT mean all types of sub services in that particular category of service are covered. Certain sub services or procedures may or may not be covered by an insurance company. Medical billers should have a strong working knowledge of this, BUT in their defense (ours, I should say), insurance companies' policies vary and then the policies change frequently. There are times when claims are handled improperly by the insurance company. Larger insurance companies process a significant amount of claims on a daily basis. Mistakes occur.
So, in a nutshell, it is important to be aware that mistakes are made on the front and back end during claims billing and handling, and this may end up affecting you adversely. I will help you understand the process so that you can easily check to see what in fact is truly your responsibility or not, and in addition to ask and get clarification before services are performed.
2. This document explains your rights and the insurance plan's responsibilities when it comes to fair claims handling, appealing adverse (in other words, not in your favor) claims decisions and handling complaints/grievances.
Whether a mistake occurs, or there is a denial of a pre-service request or an outright denial of a claim by the insurance company, there are processes in place to assist you, the patient/consumer, in getting a fair hearing in all of the above.
An insurance company or the plan administrator (if your plan is self-funded by your employer) must provide you with the details of this process in getting a fair hearing and review. Before you pick up the phone to battle with the insurance customer service representative, you need to arm yourself with this knowledge in detail. And again, trust me on this one, it is very helpful to know in order to be heard.
There will be different rules governing this process of getting a fair hearing depending on whom you get your insurance from. If you have Medicare, then you will turn to the Medicare guidelines (stated very clearly on their website and within your handbook) on how to appeal denials of services.
If you work for a company that self-funds your insurance plan (even though the company uses an insurance company to handle the claims processing), then your company must follow the guidelines for handling appeals, complaints and grievances outlined by the Federal Government in ERISA, the Employee Retirement Income Security Act.
Generally, for all other plans that are not in the two specific categories listed above, state rules apply. There are a few exceptions that may be subjected to both state and federal laws, and I will get more in-depth about this in a later blog.
The point is, you have rights and it is important to know your rights. And I will reiterate why you need to know these rights. In the process of insurance verification, billing and claims handling there will be mistakes! There will also be miscommunications and sometimes a severe lack thereof. That is why there are rules and guidelines for complaints, grievances and appealing decisions of denied services and/or denying claims. You do not need to be intimidated by this process. Denied claims and services are appealed all the time, and many are overturned.
3. This documents points to who is administering your plan and/or whom you can turn to for help.
This is important because you need someone impartial to turn to when you require specific answers and clarification to issues that are not being addressed by the insurance representative you just phoned.
You may be wondering if there is such a thing as an 'impartial' party at your private insurance company. Well, as a matter of fact, there is. If you work for a company with a self-funded plan, there is a designated person called the plan administrator whom you can go to for support and assistance. Under ERISA (remember the federal law I touched on earlier), a company is required to have a designated person who acts impartially to assist employees with their insurance issues. Typically your human resources department knows who the plan administrator is, and your summary plan description should include this information by law.
If you have individual or group insurance OTHER THAN ones that fall under the self-funded employer category above, Medicare or federally funded category, then your state can be of assistance and offer impartial help. The insurance industry is mostly state-regulated. If your insurance company becomes problematic, your state wants to know. Therefore, your state will have specific guidelines in place for your insurance company to comply with (know these before you call your insurance representative), and they will have avenues of assistance after you've exhausted those avenues with your insurance company.
For federally funded programs like Medicare, there is of course lots of assistance and support. Indeed, the federal government wants to make sure that compliance is occurring with doctors and hospitals.
On that note, I will end this blog for now. I have a feeling these blogs are going to be entirely too long and folks will have nodded off to sleep after the first few paragraphs. That's OK. You can always come back to this blog as many times as you need.
In the next blog I will talk about the explanation of benefits notice you receive from your insurance company after you have paid a visit to your doctor. I will explain step by step how to read it so that you know how much money you're truly responsible for and what services your insurance company actually paid or denied. When you receive the doctor's bill, you'll know how to approach it.
Then, over the next several blogs I will explain the whole process from insurance verification of benefits to the appeals process for claims or pre-service denials. After learning about the explanation of benefits notice, the insurance verification process and the appeals process, I will then go through various scenarios so you can get more of a handle on how to use this information.
Ok, tune in next week!