Posts Tagged ‘Medical insurance’

Maternity/Pregnancy Insurance – Claim and Appeal Process – Final Part

I hope you all had a wonderful Thanksgiving! I was finally able to relax and participate in a Turkey Trot 5k Run after taking my CFP exam last weekend. Now its wait game and I just need to wait for the exam results to come in 6 weeks.

I have more time to kill so let me finish the pending part on the Maternity Insurance. If you haven’t gone through previous posts, I recommend you check out Part 1 which introduces Maternity/Pregnancy Insurance and Part 2 discusses in details about important things to be considered.  In this last post of the series, I will discuss about the money saving part, Claims process and Appeal process if you ever need to appeal.

Like any insurance, deductible is considered as the risk rentention part where certain amount of risk is retained by the insured by paying deductible first and later expect insurance company to cover the rest according to the plan. The deductible serves as the stopping gate for the insurance companies to make sure consumer won’t go to the doctor for anything and expect insurance to pay for it. With deductible, insured always have to pay the cost until they reach the maximum deductible amount. 

It works the same way for maternity insurance (deductible plan only) as well where as you have Maternity deductible and Major medical deductible. Two deductibles run in parallel. So if you are visiting your regular doctor, its covered under Major medical deductible and when you visit your gynecologist for Maternity purpose, it will be covered under Maternity deductible.

Claims Process – Before Delivery



Anything related to the pregnancy like lab work, prescription all come under Maternity deductible. Don’t pay anything upfront. Let them process through your insurance carrier and they will send the statement after its processed. Match the statement of Claim from Insurance company and providers like labcorp and pay only the amount mentioned. These providers have standard agreed discount for each medical procedures so your insurance company will apply them and send you the final bill to be paid. You save money this way too when you have insurance. This amount is applied to your deductible.

Once you get closer to delivery date, your gynecologist office might ask to pay their charge for delivery if your deductible is high to avoid non-payment after delivery. Try to talk to them and pay may 1/3 of the charge. Also when you register in the hospital for the delivery, they also might ask you pay part of your deductible because of high deductible. Again talk to them and say you paid some to your doctor and can only pay certain amount. They will most likely work with you and accept it. 


Don’t over pay or fully pay your deductible amount
which might cause problem later because insurance company only process claims after the delivery is over and they process them accordingly how they recieve it. If your doctor sends their claim for $3500 as their delivery charge and they get processed first. You might have to pay $3500 to your doctor alone as part of your deductible. So if you paid $2500 to doctor and $2500 to hospital to cover $5000 deductible, you won’t have money to pay the doctor pending $1000 to satisfy the deductible. Hospital might refund your payment if they get paid by the insurance but it takes time. That’s why don’t pay all your deductible before delivery. You have lot of time to pay it after delivery so just talk to your providers ask them to hold for a bit.

Claims Process – After Delivery

After the delivery, if its normal process and you usually stay in the hospital for 2 days with your baby, then all charges are covered under Maternity deductible. If the delivery is complicated means C-Section and baby is normal, your delivery is covered under Major medical coverage and baby’s charges are covered under maternity coverages. That’s biggest unknown factor and you should hope for the best. If you previously delivered baby in normal delivery, you are most likely to have the future ones normal as well. You just need GOD’s grace and hope things goes well.

Otherwise, you will endup paying to cover both deductibles. You better be ready if you have bigger major medical coverage. Also you shouldn’t surprised to recieve bundles of bills from other providers like Pathologist, Anesthiologist and others apart from Hospital and Doctor’s office.


Medical Codes – Normal Vs Complicated


You might have heard about medical codes which are the important aspect of claim’s process. Your doctor or hospital has to send proper medical codes for their treatment for the insurance to process the claim properly and pay for the claim. If the medical codes were messed up, they might reject or apply the coverage under different deductibles. That’s want happened in our case. It is a normal delivery with little complication which is usual and they have different codes compared to strict normal delivery.

In our case, Doctor’s office sent a code as normal whereas Hospital intrepreted what doctor noted and sent code as normal with small complication. So insurance company processed exactly the way they sent and doctor’s claim went to maternity coverage whereas hospital cliam went to Major medical coverage even though its normal delivery. Medical codes can have big impact on the claim so be watchful on how the cliams are processed.

Appeal Process


As I mentioned above, insurance company processed claims for the same delivery differently because of the medical codes. Because they processed the codes differently,  deductibles are messed up. So I started getting bills from other providers to pay them. At one point, I got bills to pay total of  $10,000-12000 which was a shocker. I never paid them. I immediately called insurance company to understand the problem and even conferenced with hospital to let them talk each other and same time find the underlying problem. After all that going back and forth 1 month, insurance company didn’t want to pay because the claims are done as per provider codes. Hospital don’t want to change because they were claiming correctly as per doctors notes. It ended up in deadlock situation. Meanwhile I had to call other providers and requesting them to hold on their bills, many of them put 30-45 days hold.

Only option given to me by Insurance company was to appeal the claim process. So I ended up drafting a detail appeal letter mentioning what happened and what was promised when the insurance was taken. They said any normal delivery is covered under maternity coverage and now they are changing it just because of codes sent by hospital and processing them as complicated. So I requested them to reprocess all claims as normal delivery because it not right to process some claims under normal and some as complicated. I know the appeal is worth a fight to save thousands of dollars.

It took almost 3-4 months for the appeal process to be completed and they finally accepted and reprocessed the claims which are wrongly processed as normal delivery. During this time, I had to call every provider to hold them off or just pay minimum amount to extend the due date. This way they won’t go to collection. Appeal process needs constant attention and follow up. You might have to contact hospital and collect documents and send to insurance company to speedup process instead of them waiting for months. You have to do as much as possible to get this process moving and help them make the decision so you can save money. This is the last route, if it didn’t work out I was planning to file a complaint to State Insurance Commissioner to take some action. But I am glad it didn’t go that far.



Conclusion


In summary for this 3 part Maternity Insurance, I want to say, Health Insurance is a must for a family and Maternity/Pregnancy insurance is very important for any family who doesn’t have group coverage to cover their pregnancy. If you want to face it without insurance, you might end up losing lot of your savings and have tough time with the providers which might worsen your financial wellness. So I strongly recommend to consider taken maternity insurance before planning to expand your family.

5 Tips to choose a Right Healthcare Plan

In the last post, we saw the recent Health Act law changes went effect from Sept 23,2010 and more such changes are going happen for the year to come. Whether full health care bill takes effect in 2014 or not, these small changes really helps many families to maintain their health insurance coverage.  If you are individual who don’t work for any big companies that offers group health coverage and been contemplating about taking individual coverage, this may be right time before the premiums go up as many expects.

For the household which has group insurance coverage, open enrollment is right around the corner. That mean’s it’s time to start thinking about choosing your health plan for next year. Some of you might have option to select from different providers and plans but some might not have lot of wiggle room except choosing from two different plans. It all depends on your employer. But if you are individual/family without an option for getting group plan and looking to carry individual insurance you have all the options in the world.



1. What’s your status?

First, think about your current status. Are you single or married? Do you have dependents in your household who needs medical help. It matters because it determines whether you need a plan for one or a family member. Also the status will affect your cost and your health coverage. So be careful to see which plan options best suit your situation.



2. What’s the cost?

Secondly comes the cost. There are a few big things to consider about cost. Do you or your family go to the doctor often? Then you might want a plan with a lower deductible and out-of-pocket cost and a higher monthly premium. If don’t use your health plan or go to the doctor much? It might be better to choose a plan with a lower monthly premium and higher deductible. I like to categorize them as, Pay first Plans and Pay later plans.

You either pay ahead as premiums if you need lot of medical help and save money on deductibles or pay later when things happen and save money on paying high premiums.  It depends on your situation. I prefer to go with Pay later plans that way you have more flexibility but you need to plan for those expenses and put away the money aside for deductibles/coninsurances.

If you’re not sure what might be best, look at what you spent last year and how often you or your family went to the doctor. By doing your analysis and then you can choose a plan that fits your needs.



3. Who’s in the Provider network?

Third comes the provider network. Check out whether your favorite doctor is “in network” for the plans you are looking. How about specialists and hospitals nearby your area? Some don’t want to lose their favorite doctors or pediatricians while changing the plans but most of the PPO plans from different providers are pretty flexible and coverages well know doctors and clinics. But it is always better to make sure by calling the doctors office before you deciding on a particular plan.



4. Are there other benefits?


Many providers offers plan with paid preventive coverages with certain limitation and also offers wellness programs like reimbursing for fitness clubs memberships, covering certain weight loss programs. This will be the fourth step in your plan selection process.  It is common belief that one lives healthier avoids getting sick often and will have less medical problems, that reduces number of visits to hospitals and doctors and insurance companies can reduce their cost. At the same time, as a person it is important to get support to lose weight, eat healthier or stay fit. It is a win win for both insurance companies and individuals. So make sure you take a look at the wellness options.



5. Is a healthcare fund (FSA/HSA) right for you?


Finally comes some many saving options. If you currently have healthcare insurance through your employer, you might have heard about FSA cafeteria plan(FSA). This plan is offered seperately apart from your Health insurance. If you have the option to enroll in this funds, please consider it. It could help you save by paying for care with pretax dollars. Similary, HSA (Health Savings Account) also helps save money by paying premiums and deductibles from Health Saving account where the contributions to them are tax deductible and also has flexibility to earn some interest which can be withdrawan tax free when used for medical expenses. You can learn more about these plans at planforyourhealth.com.

Health problems/issues can be devastating at times and has the power to wipe out your full assets in matter of months. It is wise to have a Health insurance with reasonsable coverage to cover you and your family both for the physical and financial well being.

Some content courtesy: Aetna Newsletter

Individual Health Insurance & Healthcare Reform Act

Medical insurance is a big part of every American household. It takes about 5-10% of the income if covered by employer or more around 10-25% for self employed individuals. Self Employed individuals including myself are forced to shop for their medical insurance needs in the open individual market. With no proper regulation, they face lot of hazzles to get coverage for themselves and their family.  Without proper medical coverage is a major concern for many individuals.


The hazzle starts with coverage limitation for pre-existing conditions, even rejections in some cases, high premiums, high out of pocket expenses and much more. I myself changed insurers many times in the past 5 years just to keep low deductibles under the budget. With the new National Health Reform Act, we hoped for some relief and looks like some relief is here.


Drawbacks of Current individual insurance market


Let’s first look at some major downsides in getting individual health insurance coverage which might help to appreciate the changes.

  • An individual/self employed cannot buy coverage in the “group market” like small business or corporate companies. Employers usually cannot be turned down for coverage in the group market and also negotiation power.  Instead, the self-employed have to buy coverage in the open individual market which might allow flexibility to choose from different insurers but premium is not bargainable.
  • Also Insurance companies many times rejects applicants with pre-existing conditions and are not required to cover them at anytime. They even cancel the insurance for many individuals when they get sick very badly. So people with serious health conditions was never able to buy coverage in the individual market. Even if they do, they can only get very expensive coverage in the high risk pool, if they can afford it. On top of that, there will be annual or lifetime benefits limitation.
  • Treatment for pre-existing conditions can be excluded for up to 18 months for coverage offered to self-employed people in the individual market. Usually it is only 12 months for the coverage sold to small businesses or corporate in the group market.

Changes on the way by New Health Reform Act


That’s correct. Changes are coming on our way and we can only hope them to be good. Below are some of the proposed regulations, most of them are expected to go active by next year.

  • Insurance companies would no longer be able to deny coverage to kids with pre-existing conditions.
  • Certain annual and all lifetime limits on benefits would be prohibited.
  • Insurance companies would no longer be allowed to drop coverage when policy holders get sick.
  • Prohibits insurers from requiring policyholders to get prior authorization for emergency services.
  • Insurance companies must also spend at least 80 percent of their premium revenue on direct medical care for individual policyholders — or pay rebates, starting next year. 
  • Insurance companies will not be able reject applicants with pre-existing conditions or set premiums based on a person’s health status.
  • Individuals and Self employed people can buy coverage in the Health Insurance Exchange (just like members of Congress), where he/she can choose among competing insurance companies.

As per reports, National health reform act is expected to help around 13.1 million self-employed Americans. At the same time, there are things which still need to considered like Pregnancy coverage. I don’t see any relief for young self employed who want to grow their family. Maternity insurance is another area individual insurance doesn’t cover and hope they do something about it.