Claims – How to file a claim, get reimbursed, answers, more…

All insurance companies have claims departments. These people specialize in handling claims and deal with thousands of clients every year. Insurance companies do not permit agents or brokers to deal with claims; and, in fact, agents and brokers rarely have information about a claim. A medical ID card should always have the telephone number of the insurance company and/or their email. When contacting the company always ask for the “Claims Department.” If the “Claims Department” does not give adequate service and/or does not understand your situation, then get back to your agent. Sometimes the agent can get special attention for you in a claims matter by going through another avenue to get to the decision makers in a company. But an agent or broker is never allowed to handle claims matters. That must be done via the company’s “Claims Department.”

I have never met an insured person who enjoyed dealing with claims. It always is difficult and often a nightmare. Why is that so? Well, if you are covered with a short-term plan, medical underwriting is always done after the injury or illness. The insurance company needs to be double sure that the claim is not related to a pre-existing condition. Pre-existing conditions are not covered in short-term plans. If your claim is valid, you may wonder why they won’t accept your initial explanation as an honest explanation. Well, lying is endemic in our world, and insurance companies lose millions of dollars every year due to fraudulent claims. If they want to stay in business, they must check out every claim before they pay it.

If you are on a long-term plan, paying claims moves a little faster. The company already asked you many medical questions when you applied. Nevertheless, they will still research your claim to make sure your injury or illness was not related to a pre-existing condition you failed to reveal on your application.

Another problem is that clients often forget to calculate their deductibles and co-insurance when requesting a claims reimbursement. As a result, the reimbursement does not match their expectations. If the client has a $1,000 deductible and an 80/20 co-insurance plan with a medical bill of $10,000, he can only expect to be reimbursed $8,000. The client must pay the $1,000 deductible plus 20 percent of the first $5,000 (e.g., $1,000). Even though many international plans waive the co-insurance while overseas, co-insurance must be paid in the USA.

In a related matter, remember that you must pay your medical bills first and then be reimbursed by the insurance company. This is because American insurance companies do not have direct business relationships with medical providers outside the USA.

In order to have a happier experience when dealing with claims, keep copies of all medical bills/expenses you pay out in a special folder. Update this folder yearly. When making a claim, use your company’s claim form and send along copies of all your bills. Keep a detailed history of all your contacts with the insurance company: when you wrote them, who you talked with, what they said, etc. Be ready to wait at least six months to have your claims reimbursed. Remember that the claims department handles hundreds of claims every day. And their way of calculating your claims may be very different than yours. Ask them for an explanation when you are disappointed with the outcome. Overall, we have found the companies we work with to be fair although very careful when handling claims.

Most major health insurance companies use a national database from Igenix, a health information company, that tracks health service and care charges throughout the USA. Their database contains more than 900 million current fees in more than 270 geographic ZIP-code groupings. These groupings are broken down by three-digit, ZIP- code radius for each service. The “Usual, Reasonable and Customary” charges are based on data closest to the place of service. This method gives greater accuracy in calculating medical charges (taken from AMS Producer, 3/06).

Healthcare companies are well aware that charges for a Cat Scan in California, Florida or New York will be more than for a Cat Scan in Iowa. When they agree to pay “Usual, Reasonable and Customary” charges, they are basing those charges on what the real cost is where you received the medical care.

The wait for insurance claim reimbursement always frustrates us. Why does it take so long? In this matter we need to remember that if we take out a “guaranteed issue” policy, a policy where they ask you four or five simple questions before you are accepted for coverage, claims will take longer. The company does the underwriting after you post the claim. They need to make sure your claim has nothing to do with a pre-existing condition.

PPO plans take more time for claims reimbursement because they want to double check to make sure the claim is not based on a pre-existing condition that was not stated in the application.

It’s probably good to remember that if an insurance company takes time to research the validity of claims, in the end they are saving you money. Insurance fraud costs insurance companies millions of dollars every year, and we, the insured, pay for those lost dollars through higher premiums. Every time an insurance company can avoid paying an unjustified claim, we are the winners because it helps the company control our monthly premiums. Although that may make us feel better, patience while waiting for a claim to be paid is still a difficult art to master.

It is important to remember that international short-term health insurance is not a substitute for domestic insurance in the USA. It is only a supplement. It is to cover you for injuries and medical evacuation needed while outside the USA. If you are injured outside the USA, you must get your initial medical care outside the USA. If you only get medical care once you return to the USA, the insurance company will deny your claim.

To file a short-term health insurance claim, you need proof that you were injured outside the USA. This proof is a receipt and medical records provided by your doctor or medical practitioner outside the USA. Also make sure you get written proof that you went to the doctor while outside the USA. That will be proof to the international health insurance company that your injury took place while you were outside the USA. If you do not have that kind of documentation, your international insurance will not cover your medical costs in the USA.

When we have a valid claim, we want the insurance company to reimburse us immediately. We have submitted our claim form, and we know the illness was not related to a preexisting condition. All our documentation has been submitted to the insurance company. Why does getting reimbursed by insurance seem to take so long?

First of all, insurance companies are always careful because of fraud. Insurance companies lose tens of millions of dollars every year due to fraudulent claims. Even though yours is valid they still need to check out several things. They need to be assured that the illness is not related to a preexisting condition. The larger the claim the more careful they will be. They might ask to see the doctor?s medical records. They may want to contact your hospital in the USA. Sometimes getting these reports takes time, thus the delay in paying claims. Of course, if you break your leg or have an accident, that makes paying the claim much easier. Yet they still need all of the paperwork.

Usually count on it taking 60-90 days to get a claim paid. One company insists that their average turnaround time on a claim is 14 days–and that may be so. But note 14 days is their ?average.? That means that many claims will take less time and many will take more time.

I seldom meet a person who has processed an insurance claim and feels good about it. Why is that? The main problem is that we want quick and easy reimbursement, whereas the insurance companies want to make sure the claim is valid. Fraud causes great losses for insurance companies. So they always research the claim.

Want to know how to get reimbursed from insurance faster? Here are a few ways you can speed up the claims process:

1. Know and follow your plan. We may not enjoy reading dry material like an insurance policy but you must be familiar with what is and what is not covered by your plan as well as the policy guidelines.
2. Complete the claim form and submit it in a timely manner. Most companies require that you submit a claim within 90 days of receiving medical care. Make sure you complete the form correctly and thoroughly. List the claims in date order on the Claim Form, with the oldest date listed first. Make sure each receipt has a date of service and a diagnosis. When possible, convert monetary amounts to US dollars and translate into English the services provided.
3. Inform your insurance company when a dependent over 18 becomes a full-time student. If your company provides coverage for full-time students, they must be informed when your child changes to a full-time student status.
4. Be patient and persevere in getting the information requested to the company. If you accept from the beginning that reimbursement on your claims may take four to six months, it is easier to accept the delay.

Here is how to get reimbursed by insurance. To start with, always keep receipts of all medical care received. On the effective date of your policy every year start a new file for receipts. You need to submit all claims to the insurance company within 90 days of the medical care received, even if you have not reached your deductible. When submitting claims always submit a ?Claim Form? that is provided by your insurance company along with copies of all receipts.

If you have questions about claims, you have an e-mail address on your Medical ID card so you can e-mail the company with your questions. All claim matters are handled by the insurance company. Insurance brokers do not get involved in claims.

If response from the company is slow, e-mail them or call them. Remember, in some cases the company will research your claim; therefore, it may take 2-3 months before you are reimbursed.

When you have a medical emergency or any medical care, your first concern is not money and paying of claims. You are focusing on getting medical care. Sometimes hospitals give you the bills, and they are laid aside because you are recuperating or helping someone who is recuperating. Yet you need to be aware that there is a time limitation for submitting claims. Most international health insurance companies will not honor a claim that is submitted later than 90 days from the date of receiving the medical care. If you can?t get all of the information you need to submit a claim in a timely manner, submit the information you have along with a cover letter explaining that other information will follow. It is best to inform the insurance company as quickly as possible regarding the medical care received and the cost incurred. By all means, do not wait for 90 days (three months) to submit a medical claim. In most cases such a claim will be declined by the insuring company.

Here are a few tips for getting reimbursed by insurance. First, study your plan. Make sure you know what is covered. Read the fine print. Remember the old insurance adage: “The large print giveth and the small print taketh away.” Before receiving medical care make your health provider familiar with your plan. Always use your medical ID card when you receive treatment. If your plan requires pre-certification prior to treatment, follow the pre-certification guidelines.

Complete the claims form correctly and submit it in a timely manner–no later than 90 days from the day you received medical care. Generally, when receiving medical care in the USA, your insurance company can directly reimburse the medical provider. However, when outside the USA, you will need to pay out-of-pocket expenses and then contact the insurance company for reimbursement. After paying your provider, submit your claim form, bills, and itemized receipts to your insurance company.

When submitting your claim form, list the claims in chronological order on the form starting with the oldest claim. Make sure the date of service and diagnosis is listed on each receipt. Also put the patient’s name on each receipt.

Parade, a Sunday news magazine (9/19/2004) includes an article suggesting what we should do when our insurance won’t pay. There is not space to quote the whole article, but here are the key points:

1. Don’t get angry – but do get involved. Getting angry with service personnel is counter productive. Sometimes denials of coverage are no more than a business decision made by a computer.
2. Hold on to your written records.
3. Talk to your doctor – See if you have been denied coverage for a drug, etc., that the doctor thinks is absolutely essential for your well being.
4. Realize that most plans base coverage on ?medically necessary.? This means that you are not entitled to the newest high-tech treatments, especially if they have not been fully tested.
5. Do some research. The more you know about the medical treatment the doctor prescribed the easier it will be to talk with insurance personnel.
6. Call your insurance company and say, “I am appealing my denied care.” Then put it in writing. According to law, insurance companies need to respond in a timely manner to written appeals concerning care. It is best to send your appeal by certified or registered mail.
7. If you think a treatment or medication is urgent or required, get it. (8) If the insurance company fails to cooperate with you, then contact your state government’s Department of Insurance. All insurance companies are monitored in the USA by the Department of Insurance and must be approved by this Department to sell insurance in your state.

As with all travel insurance plans, your short-term coverage only becomes the primary coverage when you do not have USA- based insurance. If you have domestic health insurance, that company will be considered the first and primary insurer; and your international policy, for medical coverage, will function as supplemental coverage. Of course, the special benefits for international health insurance, e.g., medical evacuation, repatriation, medical reunion, lost luggage, and trip cancellation will generally be the first responsibility of your international plan.

A person in the claims department from one international insurance company explained it: Travel insurance always becomes the secondary carrier if a person has a domestic medical insurance policy. Thus our company will pay claims that the primary carrier will not cover. If there is no primary carrier, then our travel policy will kick in immediately and cover up to the max of the policy. So the insured will always need to get an EOB (Explanation of Benefits) from the primary carrier and submit that to our company in order to get reimbursement for claims.