Health insurance should protect you from financial struggles. But there are times that your policy won’t pay. Thus, before you sign a policy, make sure to know first when health insurance doesn’t pay. And if your insurer refuses to pay out, what should you do?
When Health Insurance Doesn’t Pay?
Here are some possible reasons your health insurance won’t pay for your medical bill.
1) Healthcare Provider Not in Your Plan’s Network
You can verify that your healthcare provider or doctor will accept your health insurance. However, it doesn’t necessarily mean that your policy will fully cover the medical cost.
Physicians can accept your insurance. That is, they’ll bill your policy and accept payment. However, your doctor may not be in your plan’s network.
Thus, after your appointment with your doctor, your provider’s office will charge you for the difference between the bill and the amount paid by your insurance.
2) An Error
Insurance companies can make a lot of errors. They offer inconsistent information to their clients. And it also applies to every part of the process.
If you call your insurer to inquire whether or not your policy will cover a medical procedure that you need to undergo, you should document the date and time of the call.
Now, if your insurer would not pay for such a procedure, you have the leverage to dispute your claim. You can reference that call and get your bill reduced. After all, it was the fault of its representative.
3) Not a Covered Benefit
When your health insurer won’t pay your medical bill or refuse to give you a pre-authorization request, it could mean that your plan doesn’t cover that treatment or drug.
Hence, you must get into the habit of knowing the benefits that your health plan provides and know what isn’t covered.
But don’t just rely on your health insurer. Make sure that you read your policy carefully.
If you think that your health insurer refused to pay for your medical bill even though the policy says it is covered, you can follow the appeals procedure. If your policy is job-based, make sure to ask the help of your employee benefits office.
4) Not Medically Necessary
Health insurance will only cover procedures or drugs that are medically necessary. Thus, if your claim is rejected, it could be that your health insurer doesn’t think that the care you need isn’t necessary, even though your healthcare provider requested or recommend it.
However, you should do some digging. You need to figure out what medical necessity denial actually means. When you do your research, your pre-authorization request might get approval.
But digging a little deeper means that you have to consult with an expert or ask for the help of your healthcare provider. He needs to provide the reason you need such care. Your doctor will communicate with your insurer and the latter might approve the procedure.
On the other hand, your healthcare provider and insurer might find another approach that both parties consider medically necessary.
In that case, if your claim has been denied, you must never give up. You should talk to your doctor to help you navigate the appeal process. If you do so, your health insurer might approve the procedure.
It happens when a secondary procedure is a part of a primary procedure. For instance, if you need a carpal tunnel procedure, your doctor may charge incision and carpal tunnel procedures separately. But your insurer bundles these two charges. As a result, your insurer will only pay for the carpal tunnel procedure so you will be left paying for the incision cost.
To help you file an appeal if this is the case, you must research the billing codes. If your case is too complicated, you might need to hire a medical billing advocate to help in resolving your bill.
6) No Prior Authorization
Before you can receive medical care, you may need an approved prior authorization or a referral from your doctor. If you failed to do so, then you may face a claim denial.
For instance, if you have an HMO plan but you forgot to get a referral from your primary care doctor to see a specialist, then your health insurer will deny your claim.
However, you can still appeal by asking your primary care physician to provide a statement to your health insurer that the medical services you received are necessary.
7) Missing Details
Your health insurer will request more information from your healthcare provider. In some cases, your provider might not provide the information your insurer needs or it gets lost in the process.
If you don’t make a follow-up after receiving an insurance statement, your claim might not get paid.
Fortunately, this situation can be easily resolved. You just have to follow up to make sure that your insurer receives the information it needs and that it processes the requested information properly.
What to do If Insurer Won’t Pay?
As mentioned, you can file an appeal. But if your appeal is denied, you can work with a medical billing advocate to help reduce your costs.
Medical billing advocates can negotiate with healthcare providers on your behalf.
There are several reasons when health insurance doesn’t pay. One of these might be the reason your insurer won’t pay for your medical bill. To find out more about what health insurance covers, please check out this article.