Advicemedical

Medical Review Companies Role in Your Insurance Claims – Your Health, Your Coverage, Your Guarantee

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 pound, 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 companys automatic denial of claims without really understanding the patients need contributes consumer dissatisfaction and frustration.

What Does It Have to Do With You?

Patients are people and when they need healthcare, they dont want to read the fine print or a medical dictionary, they just want their claims covered. Most often, its unlikely they would realize that their insurance claim went through an Insurance Review Organizations 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 pound 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 companys insurance review process 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 womans 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 patients medical history and the doctors 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 patients 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 patients 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 wont have to suffer misery unnecessarily nor face collections over mounting debt.

How to Appeal When Your Medical Insurance Declines Your Claim

If you are like most people, when your medical insurance declines your claim, you are left feeling helpless and frustrated. After all, if you need health care and your insurance is saying you dont, you have two choices appealing your claim or paying for the treatment out of pocket.

Most claims are declined for specific reasons and causes. The most likely cause for your health plan to deny your claim is a direct consequence of missing data. Before appealing your denied claim, you can verify that by assuring any and all pre-authorization requests were filled out with accurate patient information.

For example, is your social security number correctly listed? Does the doctor have the most current copy of your health plans identification card? Does your doctor have the most up to date copy of diagnosis and procedure codes in order to fill out the forms correctly?

By verifying that you have submitted the good documentation to the physician and they in turn submitted good documentation the health plan, you are ready to move to the next level. When it comes to dealing with your health insurance company, think paranoid.

Document every phone call, every contact person and every piece of information you are given. It only takes one break down in communication to cause a problem; by documenting all of your communication with the insurance company, you are pre-preparing for any appeals case.

If you are facing an appeals claim for treatment coverage, be sure youve reviewed the appeals process in your companys health insurance handbook. Most patients overlook reading through the handbooks their insurance company will provide. Plan requirements and appeal processes are detailed in these handbooks and you should make sure that your plan covers any treatment you are going to receive before the treatment is received, if possible.

When An Appeal Is Necessary

Since every plan should have a clear appeals process, you should follow it explicitly. You should talk to your doctor about appealing the claim so they can provide supporting documentation and expertise as needed. Remember, most insurance claims must be appealed within a limited amount of time, so if you wait six weeks after a denial and you only have 60 days to appeal; you may already be out of time.

You should always appeal internally to your insurance provider before going to an external source such as a government or state appeals process. Most appeals have a process that goes as follows:

Phone Complaint
Written Complaint
Written Appeal

This is another area where you should be very specific citing the coverage rules of your plan as well as documenting each contact you have with the insurance company. While the insurance carrier will approve the majority of valid appeals; there has been documented cases of insurance fraud and health plans that do not play by the rules. By documenting response times and any required response times; a patient can exhaust their option against the insurance carrier for a valid appeal and then take it to the next level.

Laws in many states govern an appeal to a state or federal insurance oversight process; these requirements often allow for an external, expert review of the appeal. By providing accurate documentation and detailed medical support from your physical, a board of qualified experts can then judge your case on an individual basis. If an external appeal validates the claim and overturns the denial, then your insurance company will not be able to deny the claim.
Knowledge of your health plan, your doctors knowledge of procedures and a detailed review of the appeals process are your best tools to getting the approval of the treatment you need. Do not overlook the details, keep accurate documentation and review your coverage plans if you have any questions. Remember, there are always options.