Dr. Georgiou provides important health insurance billing tips and shares if it is necessary to read the insurance coverage document.
There are so many people that have problems dealing with their insurance company and usually, the hardest time is when your insurance company has denied or refuses to pay for a medical service that you have already received. It is a really difficult system to navigate. So here are some tips.
The first thing is don’t throw the description of benefits, what your insurance company covers, into the drawer. Make sure that you read it and that you really understand what’s covered and what’s not covered and the special circumstances under which certain services are covered. I think that there’s too many people who just think that their insurance covers everything and then get surprised when there’s a denial in a claim that comes back.
The second thing is that, if in fact you get a service from your doctor or the hospital and then you receive your explanation of benefits, the form that comes back to you that says ‘denied’, ‘no payment’, ‘you are personally responsible’, then the thing to do is to go back to your benefit coverage booklet and try to understand why that decision was made by the insurance company.
Unfortunately, many times the insurance company is correct in how they issued that denial, not 100% of the time, but many times. And so it’s important for you to understand that. But if in fact you believe that a certain service should have been paid for, then the next thing to do is to get all your facts together, understand the exact language from the coverage document and to call the customer service number for your insurance company and to begin to ask questions about why a particular service was denied.
If you follow that process you will have all of the facts that you need to really begin to get to the bottom of the issue whether or not the service should be paid or not.
So the insurance coverage document itself is a very long contract that even I wouldn’t read. However, what your employer or what your insurance company sends to you is something called an SPD – a summary plan description and it really is a summary that tells you what’s covered, what’s not, and under what circumstances. So that’s pretty short and it’s really reasonable and it’s something that everyone should read before they actually try to get their insurance company to pay for anything, but if someone feels that even the summary plan description is too long to read then they should at least read the section on exclusions so that they are not caught by surprise when something gets denied later.
About Dr. Archelle Georgiou, M.D.:
Dr. Archelle Georgiou combines her deep knowledge of clinical medicine with a breadth of experience in business and health care administration to pursue her passion for simplifying the health care system. As a practicing physician and as a corporate managed care executive, Dr. Georgiou learned and leveraged the value and importance of simple and compelling communication to influence impacting patients’ personal health care behaviors as well as driving health care purchasing decisions and business growth.