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Reimbursement and Bill Payment from Predeterminations

Part 1: The Basic Tools, Chapter 3: Developing a Systematic Approach to Dealing with Health Insurance Page 6

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Such cases, in which the consumer is caught between a medical provider and an insurer, are unfortunately not unusual. There seem to be a number of situations in which no clearly agreed upon standards exist for how bills should be structured or how reimbursement should be provided. At present, medi cal providers make their own decisions on billing, and insurers make their own decisions on reimbursement. Since consumers are generally considered to be responsible for the entire medical bill-regardless of the amount of reimbursement provided by an insurer -- such situations can result in significant economic difficulty for consumers. That's why it's so important to make use of the predetermination of benefits process whenever possible.

Of course, since the predetermination of benefits process can take several weeks, it's not useful to ask a doctor to file such a request in an emergency situation or in a situation in which you need the answers to a specific medical test as quickly as possible. In addition, there's generally no value to the process if you're a participant in a managed care program and the provider is part of the managed care plan network (See Chapter 7).

However, in other cases where the test or procedure is elective or where you are willing to consider alternatives -- for example, repairing an existing piece of medical equipment rather than purchasing new equipment -- the process can be extremely helpful from an economic point of view. You need to be aware, though, that although many insurers will offer a detailed response to a predetermination of benefits request, some insurers may offer only a general statement, and will make an official determination only when the claim itself is filed. Check with your insurer to determine their specific policy rules for the predetermination of benefits process.

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