Tips for Maximizing Reimbursement from your Insurance

If you've become frustrated and overwhelmed when managing your medical bills and filing your health insurance claims you're not alone. It can be extremely difficult and time consuming for the average patient or caregiver to get through the maze of insurance land. So much bureaucracy. So much red tape.  Given the rising cost of healthcare, it is critical that claims be filed and managed correctly to ensure you receive all the payments due to you.  And to make certain that you pay only the bills you’re supposed to pay. Just because you receive a bill doesn't necessarily mean you owe money!

Carefully following the suggestions here can be of significant assistance. These tips are applicable whether you are enrolled in a traditional health insurance plan, a managed care plan (HMO, PPO), TriCare for Life, Medicare, Medicare Supplements or any other commercial insurance plan.

Even if your provider files your claims, you need to be in control of managing the process regarding reimbursement and paying bills. So many errors and denied claims are easily fixed if you know what to look for.

Here are some helpful hints to get you through the red tape, give you peace of mind and, possibly, put more money back in your pocket.

(1) Whenever possible, try to have the doctor's office file your claims and even accept assignment.  If your doctor accepts assignment, it means that he agrees to file the claim and to accept, as payment in full, the amount the insurance company approves. Your doctor cannot balance bill you for the difference between HIS CHARGE and the APPROVED AMOUNT. In most cases, the insurance company will pay the provider directly when he participates with the insurance program. If the provider accepts assignment or participates with your insurance program, your only obligation usually is the co-payment, as stated in the policy. Many providers will ask for this co-pay at the time of your visit. Try to have them bill you for the co-pay after they have filed the claim and been paid by the insurance company. Many people pay the wrong co-pay. For example, they pay 20% of the charged amount instead of 20% of the approved amount, and consequently overpay and never get back a refund.

(2) If you have more than one insurance policy, do not assume that the provider will file the claim. If you have to file the claim, be certain to give the insurance company all the information it needs. Incorrect or missing information will only cause a delay in processing the claim. If you need to submit an itemized statement, be certain the following information is included:

·        Diagnosis

·        Description of service

·        Charge for each service

·        Date of each service

·        Location of each service

·        Name of the provider (doctor, hospital) who actually treated you

·        All appropriate insurance numbers

(3) File your claims as soon as possible. Don't let the bills or receipts pile up -- and, certainly, don't save all your claims until the end of the year.  Many people think it's easier to file their claims all at once.  If you've paid the provider up front for services, you want to file as soon as possible to get back your reimbursement.  Furthermore, when you submit a claim, don't wait for it to be paid before you submit the next one.

(4) Don't pay any bill unless it is clearly understood that it is a final accounting and you are responsible for it.  Never pay a bill until you have received the Explanation of Benefits form from your insurance company, which indicates who and how much was paid.  Bills are sent prematurely and many patients pay bills before knowing if the doctor or hospital has received a payment from the insurance company.  Duplicate payments to the provider are not always returned to the patient.  Your provider may have been paid twice and owe you money.  When you do pay a bill, keep records according to the date of payment and check number.  This is necessary if you receive a duplicate bill indicating that payment has not been received, and verification of payment is required.

(5) Check your policy to be certain of the covered benefits. A lack of knowledge regarding benefits very often leads to patients being billed and paying for services that should be reimbursed or written off.  Claims are rejected for what the insurance company says are non-covered services. Always examine the explanation of benefits (EOB) to determine what was allowed and how much was paid. If you don't understand why a service was not paid, ask questions.  Call your insurance company and your provider to find out if a mistake was made.

(6) ALWAYS Appeal rejected claims regardless of the reason given by the insurance company. Providers can be very helpful, especially if they have not received payment for their service. Let them know your insurance rejected the claim. Sometimes they may have accidentally put down the wrong coding for your visit or procedure.  In addition, appeal all claims that you believe were not paid at the appropriate level.  An insurance company may say that the provider's charge "exceeds the allowed amount "("exceeds the usual and customary charge"), but this may not be the case.  A Government Accounting Office (GAO) study several years ago indicated that there's MILLIONS OF DOLLARS of rejected Medicare claims annually.  Yet, only about 2% of these rejected claims are ever appealed!  This means 98% of millions of dollars are simply ignored! Of those 2% claims that are actually appealed, approximately 75% are overturned in favor of the patient!  Think about how much money is being left on the table that is rightfully due the insured!

(7) If you have to file your own claims, make copies of everything you submit.  This will make it easier for tracking and follow-up. It will also facilitate resubmitting claims if and when the insurance company tells you they never received the information.

(8) Timely submission of claims is critical in receiving reimbursement.  Even if your provider agrees to file the claim, you should be sure that it is filed within the filing time limits imposed by the insurance company.  Claims filed too late could result in a bill to you from your provider for services that should have been paid by insurance.

Above all, don't be intimidated by the system. If you are persistent, aggressive and assertive, you will be able to maximize your reimbursement, minimize your stress and get peace of mind. And remember, you're not in this alone! Professional claims assistance organizations exist nationwide to further assist you.