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Top 4 Ways to Prevent Health Insurance Claims Problems

November 29, 2012 by helpinsureus

Of the many health insurance companies I represent, the following guidelines are valid for each. Here are four steps you can take to help minimize any “claims surprises.” Follow these steps and you may be stress-free.

  • Never rely on the assumption that a certain benefit is covered or that a particular health provider belongs to your HMO or PPO. Always double-check on whether the benefits, services or providers you need are covered before you go to get treatment. You can do this by calling your health plan’s customer-service department. Remember to take notes. Get the representative’s name and write it down, along with the date, time and general details of your conversation.  Keep these notes with your policy. If a claim problem arises and you need to file a grievance, these notes will come in handy. Most insurers customer-service phone calls are tape recorded. Having the date and time of your call will make locating your call history with the representative much easier.

  • Should you have a problem with a claim, call the insurance company CLAIMS DEPARTMENT and ask for an explanation. Again, remember to take detailed notes.

  • If the explanation is not consistent with your understanding of your health benefits, call your agent. Because of their position and their greater knowledge of the health plan details, they might be able to quickly resolve your problem.

  • If you have a claim problem that’s unresolved, file a grievance with your health plan. If you get a denial, don’t give up. In many states, the complaint eventually goes before a state sponsored grievance committee that’s outside the plan (an “external review”) or a “peer review committee” of other health care professionals. There’s always a chance the denial might be reversed.

Otherwise, your health plan is regulated by your state’s insurance department. Your state has a complaint procedure that will trigger an investigation into your problem.
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