MEDICAL INSURANCE, DID YOU READ YOUR POLICY?
Let's talk about something we all tend to overlook—reading the fine print. Many of us have signed up for subscriptions or services online, and let's be honest, most of us don't bother reading the terms of use. This habit has created a niche market for apps that cancel subscriptions on our behalf. You’ve probably seen those commercials asking how many subscriptions you have, and if you're like most people, you likely have more than you thought.
Why does this happen? It's simple: when we get to the "Terms of Use," we just check the box without reading the details. This behavior trickles into other aspects of our lives, particularly when it comes to something as important as medical insurance. We rarely read our policies, expecting everything to be covered, or we take the word of a selling agent. While agents generally have good intentions, going over every aspect of coverage in detail would take a tremendous amount of time, and you might not ask all the right questions. This leads to a common issue: many of us don't thoroughly understand what our insurance covers and, more importantly, what it doesn't.
When something isn't covered, our first reaction is often to assume the insurance company made a mistake, and our frustration is directed at them. However, many denials are not errors but are instead based on very common issues. According to ChangeHealth, the top five reasons for claim denials are:
Missing Information: Even a single blank field on a claim form can trigger a denial. Errors like a missing modifier, incorrect plan code, or missing Social Security number account for 61% of initial medical billing denials and 42% of denial write-offs.
Duplicate Claim or Service: Submitting multiple claims for the same encounter, service, or beneficiary on the same date is a major reason for Medicare Part B claim denials, accounting for up to 32%.
Service Already Adjudicated: This happens when the benefits for a service are already included in the payment or allowance for another service that has been processed.
Not Covered by Payer: Denials for services not covered under a patient’s current benefit plan can often be avoided by checking insurance details beforehand.
Expired Filing Limit: Most payers require claims to be submitted within a certain timeframe. Delays, especially those caused by correcting errors, can push claims past the deadline, leading to denials.
When a denial occurs due to lack of coverage, it's often no one's fault but our own. Understanding your policy, actually reading the details, and staying within the scope of its coverage are crucial to avoid financial pitfalls. In a country with the most expensive healthcare system in the world, with costs exceeding Germany’s by $5,000 per capita, it's vital to follow your health insurance plan to the letter.
To manage these high costs, it’s important to stay in-network, use cost-saving measures, and remember that ultimately, it's your wallet on the line. If a doctor recommends a specific hospital for lab work, consider asking if an in-office lab or an external lab organization might be more cost-effective.
Reading and understanding your policy is crucial for making informed decisions about your care. Every year, more Americans avoid seeking necessary medical treatment or prescriptions because they fear the financial implications. While the cost of healthcare is another issue entirely, one that includes inflated pharmaceutical prices and hospital charges, we still have some control over our care.
You must read and understand your medical insurance policy. Failing to do so could lead to financial disaster. Know what's covered, know the limits, and be aware of where and how you receive care, as all of these factors affect your financial responsibility.
The No Surprises Act, passed by Congress and effective from January 1, 2022, was a long-overdue measure to protect patients from surprise medical bills, especially from out-of-network providers in emergency situations. While this law is a significant step forward, it’s only a part of the solution.
Ultimately, understanding and validating what you're being told about your insurance is essential. You wouldn't buy your dream car or house based on the assumption that you won the lottery; you'd check your ticket first. Make smart choices, read your policy, and verify the information you receive. Doing so will save you a lot of grief in the long run.
KNOW YOUR PLAN, READ YOUR PLAN, UNDERSTAND YOUR PLAN, AND ASK QUESTIONS! DON’T ASSUME AND THEN FIND OUT LATER YOU WERE WRONG.
