Companies Role in Your Insurance Claims
1:11 PM
A medical review company supplies more than a second opinion. The unbiased nature of a medical review company is critical not only to the bottom dollar, but to the final result. Too often, patients think they are just numbers in a file or bits of information in a computer program. The maligned image of an insurance companyТs automatic denial of claims without really understanding the patientТs need contributes consumer dissatisfaction and frustration.
What Does It Have to Do With You?
Patients are people and when they need healthcare, they donТt want to read the fine print or a medical dictionary, they just want their claims covered. Most often, itТs unlikely they would realize that their insurance claim went through an Insurance Review OrganizationТs medical insurance review process. In fact, they probably just fill out the forms, hand a receptionist their insurance card and sign on the necessary release forms.
One of the most common complaints about needing healthcare is the cost followed closely by the complications of paperwork generated through authorization forms, claim forms and more. An insurance review organization is an intermediary company that insurance companies may outsource their claims to in order to determine with medical and insurance coverage accuracy the validity of a claim filed by someone insured by their company.
Your Health Matters
Insurance companies who deny a claim are often portrayed as heartless or more interested in the bottom dollar than they are about showing compassion. This perception is only augmented when an insurance company rejects a claim for anecdotal evidence. When a claim goes through a medical review companyТs insurance review process Ц it will not be rejected or denied based on anecdotal evidence.
For example, a patient suffers from shoulder, back and neck pain as well as bra strap grooving and eczema. Her medical history indicates years of chiropractic treatment as well as advice for non-steroidal anti-inflammatory drugs (i.e. Tylenol, Advil) and worn specialized support bras to support a 34DD frame and all of it to no success. Excessively large breasts can cause many of the symptoms the womanТs medical history indicated.
The doctor recommended a breast reduction procedure to alleviate the problem and the symptoms.
Your Coverage Matters
When the claim is submitted to the insurance company, the policy may not cover elective cosmetic procedures. Many policies do not. Claim managers lacking medical expertise will often compare a procedure request against a list of approved procedures. If cosmetic procedures are not covered, it is likely the claim will be denied. The patient is left either choosing to pay for the procedure out of pocket or continuing to suffer.
If the claim is submitted to a third party intermediary such as a medical review company, the answer will be different. The medical review company has access to a large number of medical specialist and insurance experts. The medical specialists will review the patientТs medical history and the doctorТs recommendations. When her file is reviewed, the third-party specialist will take into account the history of shoulder, neck and back pain. They will note the visits to a chiropractor and other pertinent symptoms.
If the medical specialist agrees with the patientТs physician that she is suffering from Macromastia (excessively large breasts), then he or she will understand that the cosmetic surgery of breast reduction provides the patient with the best option for the patientТs relief.
Confidence Matters
The review process may be transparent to patients whose insurance company uses a medical review company; but the effect is profound. Their coverage premiums will likely be lower. Their medical needs will be addressed. They will not see their healthcare costs rise due to the underwriting of unnecessary procedures. When it comes right down to it, a medical review company gives patients confidence that both their medical and insurance needs will be met. They wonТt have to suffer misery unnecessarily nor face collections over mounting debt.
What Does It Have to Do With You?
Patients are people and when they need healthcare, they donТt want to read the fine print or a medical dictionary, they just want their claims covered. Most often, itТs unlikely they would realize that their insurance claim went through an Insurance Review OrganizationТs medical insurance review process. In fact, they probably just fill out the forms, hand a receptionist their insurance card and sign on the necessary release forms.
One of the most common complaints about needing healthcare is the cost followed closely by the complications of paperwork generated through authorization forms, claim forms and more. An insurance review organization is an intermediary company that insurance companies may outsource their claims to in order to determine with medical and insurance coverage accuracy the validity of a claim filed by someone insured by their company.
Your Health Matters
Insurance companies who deny a claim are often portrayed as heartless or more interested in the bottom dollar than they are about showing compassion. This perception is only augmented when an insurance company rejects a claim for anecdotal evidence. When a claim goes through a medical review companyТs insurance review process Ц it will not be rejected or denied based on anecdotal evidence.
For example, a patient suffers from shoulder, back and neck pain as well as bra strap grooving and eczema. Her medical history indicates years of chiropractic treatment as well as advice for non-steroidal anti-inflammatory drugs (i.e. Tylenol, Advil) and worn specialized support bras to support a 34DD frame and all of it to no success. Excessively large breasts can cause many of the symptoms the womanТs medical history indicated.
The doctor recommended a breast reduction procedure to alleviate the problem and the symptoms.
Your Coverage Matters
When the claim is submitted to the insurance company, the policy may not cover elective cosmetic procedures. Many policies do not. Claim managers lacking medical expertise will often compare a procedure request against a list of approved procedures. If cosmetic procedures are not covered, it is likely the claim will be denied. The patient is left either choosing to pay for the procedure out of pocket or continuing to suffer.
If the claim is submitted to a third party intermediary such as a medical review company, the answer will be different. The medical review company has access to a large number of medical specialist and insurance experts. The medical specialists will review the patientТs medical history and the doctorТs recommendations. When her file is reviewed, the third-party specialist will take into account the history of shoulder, neck and back pain. They will note the visits to a chiropractor and other pertinent symptoms.
If the medical specialist agrees with the patientТs physician that she is suffering from Macromastia (excessively large breasts), then he or she will understand that the cosmetic surgery of breast reduction provides the patient with the best option for the patientТs relief.
Confidence Matters
The review process may be transparent to patients whose insurance company uses a medical review company; but the effect is profound. Their coverage premiums will likely be lower. Their medical needs will be addressed. They will not see their healthcare costs rise due to the underwriting of unnecessary procedures. When it comes right down to it, a medical review company gives patients confidence that both their medical and insurance needs will be met. They wonТt have to suffer misery unnecessarily nor face collections over mounting debt.
Health Insurance - Is Some Better Than None?
11:04 AM
About 50 years ago, health insurance started to be an attractive incentive offered by employers to attract and keep good employees. Overall, group plans tended to be inexpensive for employers, with employees contributing a small amount of money or none at all to secure health insurance for themselves and their families.
It was more expensive for individuals to pay for non-group policies, but coverage was fairly affordable. Then medical costs started to rise, people started to live longer and the medical profession became adept at curing various diseases and saving and prolonging the lives of people with serious injuries and life-threatening illnesses. Health care and insurance prices started rising much more quickly than annual incomes and premiums began taxing both employers, who were paying the lionТs share of premiums, and for employees, to whom businesses often passed on costs through larger deductibles, greater out of pocket expenses and higher premiums.
According to a recent report by the MSNBC News Service, 41 percent of Americans whose income ranges from moderate to middle had no health insurance for at least part of 2005. In 2001, that number was much lowerЧ28 percent. Additionally, more than 50 percent of uninsured Americans in 2005 found it difficult to pay their medical bills. Another alarming statisticЧ28 percent of Americans in 2005 had no health insurance, while 24 percent had none in 2001.
So, what should a person do if they donТt have any health insurance or if they have a choice between a cheap discount plan that does not cover core expenses and an affordable plan that may cost a bit more but also provides much better coverage? According to data from the U.S. Centers for Disease Control and Prevention, the majority of people who are not covered for important screening tests, such as a mammogram, colon cancer screening or a PSA test, will not undergo those exams. Also, close to 60 percent of people without health insurance missed treatment or did not buy medicine needed for a chronic condition.
All of these figures point to one thingЧpeople who lack health coverage for essential services are often unable to pay for those services, putting them at greater risk for developing new or exacerbating existent health conditions.
What should you look for in a health insurance plan, especially when cost is an issue? ItТs important that you get the best coverage you can afford. Skimping on premiums can save you money upfront, but the result can prove to be penny-wise and pound-foolish. Sometimes people canТt afford coverage and sometimes they believe because they are healthy that they simply donТt need it. However, healthy people get ill or are involved in serious accidents all the time. You never know when youТll need coverage.
Some people opt for УcatastrophicФ insurance, which usually covers only major medical and hospital expenses above a specific deductible. Under such a plan, the insured pays for routine doctor visits and prescription drugs. With this type of plan, youТll pay a low monthly premium but will also have a high deductible and limited coverage. Deductibles start at $500 per year but can be considerably more. If you purchase an inexpensive policy with a $10,000 deductible and you undergo surgery that costs $8,000, you must pay that $8,000. If your surgery costs $12,000, you would owe $10,000.
One insurance company offers a plan that costs $29 per month for a 21 year-old, non-smoking female. ThereТs a yearly $250 deductible and $2,500 in out of pocket expenses that the insured must pay before the policy kicks in. Hospital, surgical and x-ray expenses are covered but other costs, such as doctor visits, prescription drugs, maternity care and mental healthcare are not included. ThereТs a lifetime maximum of $1 million.
ItТs certainly a bargain, if you donТt plan on going to the doctor very often. To enroll in a plan that will cover doctor visits, prescriptions, maternity expenses and more could easily cost $400 per monthЧa jump of $371 every 30 days for a total cost of $4,800 per year!
Group health insurance plans, which you can usually enroll in through your employer, union or guild, are the best buy. Individual plans, especially those that offer comprehensive coverage, can be crippling to many peopleТs pocketbooks. When buying health insurance, itТs important to shop around. Your choice of what type of plan you purchase will be determined by what you can afford and what you need as far as insurance is concerned. ThereТs no right or wrong choice when it comes to health insurance but at the very least you should have catastrophic insurance.
There are basically three types of plansЧFee-For-Service, Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO). Fee-For-Service plans offer the most choice regarding doctors and hospitals but they often involve quite a bit of paperwork and are the most expensive. If youТre willing to give up some or a lot of choice, do less paperwork and save some money on premiums then either a HMO or a PPO is for you.
A HMO offers the least amount of choice, involves co-pays, has the least amount of paperwork and is the cheapest of the three types of insurance. A PPO combines some elements of Fee-For-Service and a HMO. YouТll have more choice than you would with a HMO but less than you would with a Fee-For-Service plan. It tends to be more expensive than a HMO but less expensive than Fee-For-Service. All three types of insurance have some aspect of Managed CareЧwhich determines how much health care you can useЧattached to them, with Fee-For-Service having the fewest restrictions and a HMO being restricted the most.
When shopping for health insurance ask the following questionsЧ
* How much is the premium?
* What services are covered?
* What are the total deductible and out of pocket expenses per year?
* How much are the co-pays?
* What is the maximum lifetime benefit?
* How much freedom will you have when choosing doctors and hospitals?
* What are the pre-approval procedures for seeing specialists, undergoing a procedure or being given a test?
* What prescription drugs are covered and to what degree?
* Is mental health covered and to what degree?
* Is dental covered and to what degree?
As you begin to narrow down your choices, you can look more closely at specific plans that seem to fit your needs and determine which offer you the best value for your dollar?
America has one of the finest healthcare systems in the world and one of the most complex health insurance systems across the globe. Often, they seem to be at odds with one another, unable to communicate and work together. That can be one of the most frustrating parts of anyoneТs foray into the world of healthcare professionals, hospitals and health insurance companies. For this reason alone, itТs important that you carefully and thoughtfully choose your healthcare benefits provider.
It was more expensive for individuals to pay for non-group policies, but coverage was fairly affordable. Then medical costs started to rise, people started to live longer and the medical profession became adept at curing various diseases and saving and prolonging the lives of people with serious injuries and life-threatening illnesses. Health care and insurance prices started rising much more quickly than annual incomes and premiums began taxing both employers, who were paying the lionТs share of premiums, and for employees, to whom businesses often passed on costs through larger deductibles, greater out of pocket expenses and higher premiums.
According to a recent report by the MSNBC News Service, 41 percent of Americans whose income ranges from moderate to middle had no health insurance for at least part of 2005. In 2001, that number was much lowerЧ28 percent. Additionally, more than 50 percent of uninsured Americans in 2005 found it difficult to pay their medical bills. Another alarming statisticЧ28 percent of Americans in 2005 had no health insurance, while 24 percent had none in 2001.
So, what should a person do if they donТt have any health insurance or if they have a choice between a cheap discount plan that does not cover core expenses and an affordable plan that may cost a bit more but also provides much better coverage? According to data from the U.S. Centers for Disease Control and Prevention, the majority of people who are not covered for important screening tests, such as a mammogram, colon cancer screening or a PSA test, will not undergo those exams. Also, close to 60 percent of people without health insurance missed treatment or did not buy medicine needed for a chronic condition.
All of these figures point to one thingЧpeople who lack health coverage for essential services are often unable to pay for those services, putting them at greater risk for developing new or exacerbating existent health conditions.
What should you look for in a health insurance plan, especially when cost is an issue? ItТs important that you get the best coverage you can afford. Skimping on premiums can save you money upfront, but the result can prove to be penny-wise and pound-foolish. Sometimes people canТt afford coverage and sometimes they believe because they are healthy that they simply donТt need it. However, healthy people get ill or are involved in serious accidents all the time. You never know when youТll need coverage.
Some people opt for УcatastrophicФ insurance, which usually covers only major medical and hospital expenses above a specific deductible. Under such a plan, the insured pays for routine doctor visits and prescription drugs. With this type of plan, youТll pay a low monthly premium but will also have a high deductible and limited coverage. Deductibles start at $500 per year but can be considerably more. If you purchase an inexpensive policy with a $10,000 deductible and you undergo surgery that costs $8,000, you must pay that $8,000. If your surgery costs $12,000, you would owe $10,000.
One insurance company offers a plan that costs $29 per month for a 21 year-old, non-smoking female. ThereТs a yearly $250 deductible and $2,500 in out of pocket expenses that the insured must pay before the policy kicks in. Hospital, surgical and x-ray expenses are covered but other costs, such as doctor visits, prescription drugs, maternity care and mental healthcare are not included. ThereТs a lifetime maximum of $1 million.
ItТs certainly a bargain, if you donТt plan on going to the doctor very often. To enroll in a plan that will cover doctor visits, prescriptions, maternity expenses and more could easily cost $400 per monthЧa jump of $371 every 30 days for a total cost of $4,800 per year!
Group health insurance plans, which you can usually enroll in through your employer, union or guild, are the best buy. Individual plans, especially those that offer comprehensive coverage, can be crippling to many peopleТs pocketbooks. When buying health insurance, itТs important to shop around. Your choice of what type of plan you purchase will be determined by what you can afford and what you need as far as insurance is concerned. ThereТs no right or wrong choice when it comes to health insurance but at the very least you should have catastrophic insurance.
There are basically three types of plansЧFee-For-Service, Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO). Fee-For-Service plans offer the most choice regarding doctors and hospitals but they often involve quite a bit of paperwork and are the most expensive. If youТre willing to give up some or a lot of choice, do less paperwork and save some money on premiums then either a HMO or a PPO is for you.
A HMO offers the least amount of choice, involves co-pays, has the least amount of paperwork and is the cheapest of the three types of insurance. A PPO combines some elements of Fee-For-Service and a HMO. YouТll have more choice than you would with a HMO but less than you would with a Fee-For-Service plan. It tends to be more expensive than a HMO but less expensive than Fee-For-Service. All three types of insurance have some aspect of Managed CareЧwhich determines how much health care you can useЧattached to them, with Fee-For-Service having the fewest restrictions and a HMO being restricted the most.
When shopping for health insurance ask the following questionsЧ
* How much is the premium?
* What services are covered?
* What are the total deductible and out of pocket expenses per year?
* How much are the co-pays?
* What is the maximum lifetime benefit?
* How much freedom will you have when choosing doctors and hospitals?
* What are the pre-approval procedures for seeing specialists, undergoing a procedure or being given a test?
* What prescription drugs are covered and to what degree?
* Is mental health covered and to what degree?
* Is dental covered and to what degree?
As you begin to narrow down your choices, you can look more closely at specific plans that seem to fit your needs and determine which offer you the best value for your dollar?
America has one of the finest healthcare systems in the world and one of the most complex health insurance systems across the globe. Often, they seem to be at odds with one another, unable to communicate and work together. That can be one of the most frustrating parts of anyoneТs foray into the world of healthcare professionals, hospitals and health insurance companies. For this reason alone, itТs important that you carefully and thoughtfully choose your healthcare benefits provider.