Dr. Georgiou provides important health insurance billing tips and shares if it is necessary to read the insurance coverage document.
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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 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 in to 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 gets 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 received your explanation of benefits. The form that comes back to you that says denied no payment, you’re 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 and how they issue that denial, not a hundred percent of the time but many times. 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 ask questions about why a particular service is denied. If you follow that process you will have all of the facts that you need to be really begin to get to the bottom of the issue of whether or not the issue will 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 if the summary plan description is too long to read then they should at least read the section on exclusions. So that they’re not caught by surprise when something gets denied later.
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