About Healthcare Coverage
Health insurance helps pay for costly medical treatment and can protect you and your family from financial hardship. There are different types of private and pubic health insurance programs. Some people have private health insurance coverage either through an employer (often called a group plan) or through an individual policy they've purchased. Even if you have coverage, certain treatments and charges may not be included or paid in full. And then there's the sometimes overwhelming task of filing or appealing health insurance claims, especially when you're undergoing cancer treatment.
Ask family or friends to help you manage the maze of health insurance claims, keep organized records and file appeals if needed. Putting a trusted relative or friend in charge of insurance can take an enormous burden off you.
Read your health insurance policy carefully to understand the health and medical services covered. Find out the portion of medical expenses you're responsible for paying, such as premiums, deductibles, co-payments, co-insurance and lifetime maximum, or "cap." For plan years that began on or after September 23, 2010, plans can no longer impose lifetime caps and beginning in 2014, eliminate annual limits on coverage, due to the Patient Protection and Affordable Care Act.
To better manage your health finances and get the most from your insurance coverage:
- Check that the personal information on your policy is correct.
- Review the policy's summary of benefits, noting any coverage exclusions or limits. Don't overlook riders or endorsement forms.
- Keep a copy of all claims and related paperwork, such as letters of medical necessity, bills, receipts and requests for sick leave.
- Keep a written record of phone conversations with insurers.
- Check your health policy often to determine what services and medications are covered.
- Obtain proof of previous health insurance coverage, called a certificate of creditable coverage, from former employers and insurers.
- Pay premiums on time and in full to avoid a lapse in coverage.
- Learn what to do if a claim is denied.
- Know the laws designed to protect patients and provide continuation of medical coverage (for example, COBRA, HIPAA, Family and Medical Leave Act, Americans with Disabilities Act).
If your insurance company denies payment for a recommended treatment, you may be able to get a decision overturned by filing an appeal. Ask your insurer the following questions when appealing a denial of coverage:
- Can you send me a copy of the denial letter?
- What is the specific reason the claim was denied? (This information should be included in the denial letter.)
- How can I get a current copy of the plan document and plan summary? (You may need to request these documents in writing.)
- Whom can I contact at the insurance company to discuss the denial? May I have that person's direct phone number?
- How can I request a physician peer review? (A peer review provides the chance for your doctor to discuss your treatment in detail with other doctors, usually within the same geographic area and medical specialty.)
- Can I speak with anyone else if I have questions about the appeals process?
- If a particular drug isn't on the prescription plan's covered drug list (formulary), what is the process for requesting an exception? Can my doctor submit a letter explaining why the drug is needed?
Record the date and time of each call to the insurance company, and the name, phone number and extension of the representative you speak with. Remain courteous, honor deadlines for obtaining key documents and submit all necessary paperwork - important elements to improve the likelihood of a successful appeal.