Introduction to Traditional Individual and Group Plans, Hospital Bills
Part 2, Chapter 5: Traditional Individual and Group Plans, Hospital Bills Page 1
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Years ago, it was fairly easy to deal with hospital (inpatient) claims. When you were admitted to a hospital, all you generally had to do was to give the hospital billing office a copy of your insurance identification card. The hospital then filed the claim with your insurer and took care of all the details. These days, with pre-authorization requirements, co-payments, outpatient pre-admission testing, and other innovations, a consumer has to be closely involved in order to be certain that everything is progressing properly in terms of the billing and claim-filing process.
Becoming Familiar with Policy Rules
It's essential that you understand your health insurance policy rules in regard to reimbursement for hospital services. For example, you need to determine whether your policy provides coverage for a private hospital room in some circumstances or for a semi-private room only. In addition, you need to determine the extent to which coverage is provided for intensive care, and you need to determine whether or not the policy requires that pre-admission testing be performed prior to hospitalization in a non-emergency situation.
Most importantly, it's essential to determine whether your health insurance policy requires that you, a family member, or a hospital representative call your insurance company prior to admission to a hospital or prior to a transfer to a hospital intensive care unit. That requirement is generally referred to as pre-authorization. Policies that require pre-authorization may provide for penalties for failing to call prior to hospitalization, including a significant reduction in benefits. You also need to determine what the process is for obtaining such pre-authorization, particularly on weekends, holidays, and in emergency situations.
If your policy requires pre-authorization prior to hospitalization, when you call the insurance company it's essential that you write down the date, the time, and the name of the person with whom you have spoken. That will help to ensure that there will be a record of the telephone call if questions occur later about whether pre-authorization was obtained. Since decisions in regard to hospitalization are often made on an emergency basis, it's important to research these issues well in advance of the need for the information and to place the answers in your information file.
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