During your lifetime, you will be asked to verify your health insurance periodically. You may change your doctor, schedule a surgical procedure, or even give birth. Health insurance verification is vital to the billing process. It helps medical professionals confirm your coverage and your financial obligations.
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According to the American Medical Association health insurance verification is part of a larger procedure that occurs during registration and must be completed before any medical attention is rendered. Your doctor’s staff must know the exact limits of your policy and what your payment responsibilities are.
How does the health verification process work?
The limits of your policy can be related to costs such as your co-payment fees or lab fees. They may have certain restrictions and guidelines. If there are any discrepancies, they are resolved effectively by utilizing the health insurance verification process.
Patients and doctors work together to complete the health insurance verification process. As a patient, it is your responsibility to complete medical forms and produce insurance information. With your consent, your doctor uses this data to verify your eligibility. If your insurance company will not cover a procedure, you are notified so other options can be exercised.
Most times, health insurance verification is a routine task and takes very little time to complete. However, it is very important for you to understand:
- Your health insurance policy
- How your coverage works
- What is expected of you if an unexpected situation occurs
What happens if I am not covered for an illness or condition?
Unfortunately, many people are not able to receive the medical attention they require because of denials. Your plan may not cover preexisting conditions, or they may not feel that your medical situation warrants the treatment you are seeking. Is your doctor an out-of-network physician? This may be another reason.
Once your doctor completes the health verification process, you will receive notification immediately. If your insurance provider denies coverage, your doctor can still treat you but you will be responsible for all of the costs associated with your procedure.
Medical costs can soar into the thousands if your insurance provider fails to authorize payment. Instead of you accepting responsibility for approximately 20% of the fees (or with HMO providers, 100%), you are expected to pay each bill, in full. In cases such as these, you can opt to be placed on a payment schedule.
You should know your rights to receive proper healthcare when you are ill. It is imperative that you discuss alternative methods with your physician. Address your medical situation and act quickly if they do not approve. Your insurance company has an appeal process that you should utilize if they deny payment for medical treatment.
How do I apply for an appeal?
Before you begin the appeal process, you should take a deep-dive into your health insurance policy. Find out if there are any time limits on the appeal process and what their responsibility is once they receive the complaint. Having this information will come in handy during your initial correspondence. You should be prepared for a long haul however; appeals can take time to resolve.
Laws vary from state to state, so be sure to verify your state’s laws to make sure you are following the correct steps. The basis of most appeals surrounds the insurance company denying your coverage because they feel it is not a medical requirement. You will need to provide written documentation proving how you will be affected without medical aid.
Once you have gathered all of your medical paperwork, reach out to your insurance company directly. Email correspondence often works better than telephone calls because the emails are time-stamped. Put your complaint on public record with your insurance company and request a resolution timeframe. 30 days is standard.
If your issue needs to be escalated due to lack of follow-up from the insurance company or sense of urgency, you can contact the Better Business Bureau and your state’s Department of Insurance for assistance. They will provide you with contacts and programs specific to your state and help expedite your complaint.
The reality is many Americans are not aware of the stipulations and fine print associated with their health insurance policies. It is your job to find out all of the facts before you are placed in a position where you need medical assistance and are not eligible. Knowledge is your best defense against the unknown. When you have all of the information, you can make educated decisions.
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