6 Reasons Insurance Didn’t Cover Your Medical Bills
6 Reasons Health Insurance Didn’t Cover Your Medical Bill
You are not alone if you have been surprised by the high cost of a medical bill or service that should have been covered by your insurance company. According to the US Department of Labor, 200 million health insurance claims are refused each year.
Understanding why health insurance claims are often refused is critical for financial management. You can maximize your benefits and save money by understanding what is and is not covered.
Best of all, we've done all of the legwork. Continue reading to learn the most common reasons your insurance company did not pay the complete cost.
1. Provider Network Issues
Simply because your doctor takes your insurance doesn't guarantee you're fully covered. When a doctor says they "accept your insurance," it indicates they will bill your insurer and accept payment, but it does not guarantee they are in your network. If you go outside the provider network, your insurer will most likely refuse your claim. The doctor's office can "balance bill" you after your appointment, which means you will be charged the difference between what was invoiced and what your insurance paid. This is due to the fact that your provider has not signed a network agreement with your insurance company.
If you require prior authorization for a service to be done by an out-of-network physician, your insurance company may deny it but will consider it if you choose a different healthcare provider.
2. Your Free Annual Examination Wasn’t Actually Free
According to the Affordable Care Act, all yearly physicals must be provided at no cost to policyholders—so why were you charged for yours? The truth, it turns out, is hidden in the small print. If you go to your doctor for a free test but then have something done that isn't part of the free exam, the entire exam is chargeable. For example, if you go in for an annual exam but request an electrocardiogram test from your doctor because you're concerned about heart problems, the exam can be billed as an examination with EKG testing, which is no longer free. Before requesting additional services during your free test, make sure it won't be billed as an exam with diagnosis.
3. Your Insurance Company Practices “Bundling”
"Bundling" refers to a form of miscommunication between your healthcare provider and your insurer in the medical field. It occurs when a secondary operation is regarded as a component of a primary process. For example, if an incision is required prior to a specific procedure, the surgeon may treat the incision and surgery as different charges and bill them individually. However, the misconception occurs when your insurance company "bundles" the two procedures and only pays out one claim. In this situation, you would be responsible for paying the incision claim bill. Each bundling scenario is unique because the insurance company is sometimes accurate and the doctor is sometimes correct. These instances necessitate a significant amount of medical study, ranging from the correct billing codes to what happened during the treatment and the specialty's usual billing processes. As a result, you may find it beneficial to talk with a medical billing professional who can assist you in resolving your debt.
4. Your Claim Is Missing information
Before paying a claim, your insurance provider may require further information from your doctor. However, if your provider does not supply the information or it is lost in the insurance company's processing, your claim may never be paid. This is where a little research may help you save a lot of money. Follow up the next time you receive a statement indicating that nothing was paid to confirm that your insurance company received and processed all relevant information pertaining to your claim.
5. Your Hospitalization Was Incorrectly Classified
When you require immediate, emergency care, your position as a hospital patient is determined by the degree of care you require. You will be placed in one of two categories: observation status or inpatient status. When you are in the hospital and require complex treatment, or if you require more than a day or two of care, you are considered an inpatient. If, on the other hand, you are placed in a bed but have a low likelihood of requiring long-term care, observation status will most likely apply. If your health insurance refuses to pay for a hospital stay, the explanation could be a disagreement over the correct status of your hospitalization, rather than a disagreement over whether or not you needed the service. Sometimes the hospital and your doctor believe you should be admitted to the hospital as an inpatient, while your insurer believes you should have been treated as an observation patient.
6. Your Insurer Questions the Medical Necessity of Your Care
If your claim or pre-authorization request was denied due to medical necessity, it's possible that your insurer believes you don't need the care your doctor has advised, whether it's a test, treatment, or prescription. In this case, you'll need to seek the assistance of your healthcare physician. They will be able to contact your insurance carrier on your behalf, providing further details about why you require the desired service. After all, the Affordable Care Act offers consumers the right to an internal and external appeals procedure for non-grandfathered health plans. That is, if you successfully navigate the appeals procedure, you may be able to get your service approved. Alternatively, you may be able to make an agreement that allows you to keep coverage for care that is appropriate for your situation.