How to Talk to Your Health Insurance Company: Explained
Key Takeaways
- Be prepared to discuss with your health insurance company and have all the assets they may ask for during the conversation.
- Your medical records and personal information is private and protected during conversations with your healthcare insurance company.
- If you’re not satisfied with a bill’s outcome from your health insurance company, give them a call to discuss options, potential errors, and next steps.
Speaking with your health insurance company doesn’t have to be confusing. Armed with the right information, ensuring you’re prepared for the conversation and asking the right questions can make the discussion worth your time. Here are a few things to consider to make the next call with your health insurance carrier valuable.
My Medicare coverage doesn’t address all of my needs.
Are You Prepared?
While talking to a representative from your health insurance company, you will want to be prepared and have all the information they will need. A few items you may need include:
- Mailing address and date of birth
- Insurance policy number on your insurance card
- A Medicare Summary Notice or an Explanation of Benefits
- Any medical bills you’ve received that you need to discuss. Ensure that the bill includes the name and address of the sender, the doctor’s name and/or hospital, date of service, and the diagnosis code.
- Mailing address and date of birth
- Insurance policy number from insurance car
- Medicare card or social security number
- A Medicare Summary Notice or an Explanation of Benefits
- Any medical bills you’ve received that you need to discuss
What Is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets a national standard for privacy, provides limited privacy for medical records maintained by health care providers, health plans, and health clearinghouses.
Doctors, nurses and hospitals can view and share your medical records to ensure you receive proper healthcare treatment. An example of this is your primary care physician referring you to a specialist and needing to share your medical information and history. Additionally, insurance companies need access to your health information to verify and process claims.
Looking for a plan with prescription drug coverage?
What to do if your Insurance Carrier Doesn’t Cover a Doctor, Service, etc.?
If your doctor has ordered you to visit a specialist or begin a prescription regimen, it doesn’t mean that your insurance carrier will cover it. That means when you see an out-of-network referred specialist or received a test or treatment that isn’t covered, your insurance company will not pay their portion of the bill.
There are a few things to keep in mind if a procedure or test is not covered:
Ask Your Doctor for Covered Alternatives: if your doctor prescribes you a name brand medication that is not fully covered by your insurance, ask your doctor if there is a generic alternative. Additionally, if they provide an out-of-network referral specialist, ask for an in-network referral.
Appeal the Claim: If your insurance company denies a claim, you can appeal the decision. You’ll need to determine why the health insurance claim was denied and understand your insurance company’s policy on the appeal process and deadlines. Also, it may be beneficial to ask your doctor for their opinion about the appeal, and they may be able to assist you through the appeals process.
Ask for a Payment Plan: If you need to pay out of pocket because your insurance carrier doesn’t cover a procedure, talk with the doctor’s office and inquire about a discount, cash price, or interest-free payment plan.
What is the Explanation of Benefits (EOB)?
An explanation of benefits (EOB) is the insurance company’s written explanation regarding a health insurance claim, showing what the insurance company paid, applied discounts and what the patient must pay.
Check to ensure all information on the EOB, such as the dates and services, are correct. If you’re having difficulties understanding an EOB, call your insurance company and ask specific questions and have them provide you with an explanation of the statement for clarification.
I found an error in my Explanation of Benefits. What do I do?
What are a deductible and copayment?
A copayment is a flat or fixed amount that you pay for a covered healthcare service on the spot each time you see your doctor or fill a prescription.