Last updated: Mar 02, 2016
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Call your insurance company before a procedure is scheduled to make sure you're covered.
(ISTOCKPHOTO/HEALTH)
The last thing anyone suffering from a long-term health condition needs is to become embroiled in a drawn-out fight with an insurance company over treatment payments. The best protection is preemption. If youre having a scheduled procedure, talk to your health-care provider and your insurance company ahead of time. “Youve got to make sure up front that the treatment is going to be covered,” says Nora Johnson, vice president and director of education and compliance for Medical Billing Advocates of America. Here, she shares the key questions to ask so you dont end up paying out-of-pocket for your medical expenses.


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Is this treatment considered experimental? Insurance companies will only pay for procedures that, in their view, are well-proven to be effective. “If your doctor says, ‘There is a new treatment that I think could really work on you, of course youre going to say you want it. But the doctor may not know, and you may not know, that the insurance company considers this treatment experimental,” says Johnson. If thats the case, ask your doctor whether he or she can help you argue that it should be covered anyway. You may have to file an appeal with your insurer and, if you do get permission, be sure to get it in writing. Indeed, its a good idea to get written preapproval for all procedures, even if its not required.


Have we established medical necessity? Likewise, your insurer will want to be sure that your condition warrants the treatment. If you have a variety of symptoms, what your doctor highlights could make the difference between coverage and no coverage. “A headache diagnosis is not going to establish medical necessity for an abdominal CAT scan,” says Johnson, even if your doctor orders it. “They would have to list vomiting or stomach pain as a diagnosis to justify the procedure. If your insurance company says it wont cover the procedure, discuss with your doctor whether there is any leeway in the diagnosis that could provide the needed justification.”

What is the proper diagnostic code to be used for billing? The next step is to make sure the diagnosis and recommended treatment are properly reflected in the billing codes. “Medical coding is the very foundation of all medical reimbursement. If something is coded wrong, the insurance company is likely to deny it,” Johnson says. Ask the billing department of your doctors office or hospital how the procedure will appear on the bill, and then try to get your insurance company to confirm that it will be covered.

Are all the practitioners on the team in-network? Even if you are being treated at a hospital that is in your insurers provider network, there may be doctors treating you there who are not—say, the anesthesiologist on your surgery team. In that case, call your insurer or go online, see which anesthesiologists are in your network, then call the hospital and say you want an anesthesiologist who participates with your insurance, advises Johnson. "You may be told that there are no participating anesthesiologists in the area that have privileges at this hospital," she says. "Demand to speak with the anesthesiologist who will be assigned to your case, and insist that your insurance company's 'allowed amount' be accepted as payment in full for anesthesia services. And get the agreement signed and in writing!"