This article concentrates Medical Coverage on every aspects of pre-visit screening- probably this is the phase where various health insurance problems originate and later gives a big trouble to both the party. A policyholder selects and purchases a policy from the heaps of health insurance plans. Nearly everyone provide comprehensive medical services to the insured because of pre-mediated fees with the consulting doctors and medical facilities. The medical referrals from the in-network physician have advantages over choosing the medical services from outside. The details of covered medical expenses sometimes, remain unclear to the insured. The denied medical claims are the results of misunderstanding of the insurance contracts between the health insurer and provider. The provider must have thorough knowledge of the insurance policy under which the claims has to be submitted. For this purpose, administrative records are prepared and the reimbursement history is studied from time to time to understand the process of claim validation.
For many medical services, sometimes it becomes difficult to determine whether the health insurer will provide reimbursement benefits for the rendered services. This is because of undefined reimbursement terms in the insurance policy. It is advisable to study the insurance policy properly prior to signing it. It is important for the insurer to provide comprehensive details about the Current Procedural Terminology codes and corresponding payment methodology.
Changing the Terms:
An insurance policy may contain the directions about the possibility in change of reimbursement terms under some circumstances. These small instructions might be conspicuously stated which may not interest the insured to go through in detail. These terms are essential to cut out the insurance risk associated with the policy. The provider should therefore, read through the policy so that claims submission could be properly done, leaving out the chances of reimbursement denial. Further, the provider can assess the policy for the provision of notice in case of change of terms and provision of cancelling the policy if the change of terms is unacceptable.
The medical insurance providers are conscious about the payment time due to administrative reasons. However, no language in the insurance policy laying the guidelines of prompt payment often leaves the things in disarray. There is increased administrative workload, office and clients follow up. Some states have specific laws related to prompt payment. The provider is required to observe these laws and embark the legal action if the insurer fails comply with them.
Since there is no comprehensive list of suitable medical services which are covered, there should be clear description regarding “medically necessary.” Some medical services are gauged against the insurance rules like least costly alternative for the purposes of reimbursement. Under “medically necessary, a health insurer promises to pay for medical services if they are medically necessary. The provider should carefully read these terms and determine if the policy defines the required medical services as necessary. Lack of these terms result in denied claims which adversely impacts the insured’s financial means and medical treatment.
Some properly formed medical claims are denied because the provider is unable to follow the prior authorization rule stated in the insurance policy. Some insurers make it necessary to the insured to get prior authorization for specific medical services. These prior authorizations can be obtained within specific time limit and also valid for specific time limit. The insurer can legally deny reimbursing the claims, if these directions are not followed. Since the fees are pre-mediated and works in favor of both the insurer and the insured, the common practice followed by the providers is to prepare a list of procedure which requires prior authorizations.