How To Avoid Claims Denials And Medical Debt
Ed Zaleck | Oct 22, 2024 Insurance
As an international student, purchasing an insurance is the best way to protect yourself against expensive costs for medical services in the U.S. However, insurance does not cover for all medical expenses and claims are subject to denial based on your plan benefits.
Having to pay the cost of a surgery or an ER visit can put you in major debt and threaten your ability to support yourself in the U.S. – so avoiding claims denials is of the utmost importance. We’ve prepared some information below to make sure you avoid claims denials into the future.
How To Avoid Claims Denials
1. Become Familiar Your Insurance Plan Details
The best way to avoid claims denials is to be proactive and take your time to review your plan while purchasing insurance. The key thing to review is your plan’s exclusions section, as it will contain a list of services your plan does not cover.
In particular for international student insurance plans, make sure to review if the following are excluded:
- Pre-existing conditions - Many insurance plans do not cover pre-existing conditions or have a waiting period for them. If you have an injury/sickness you need treatment for prior to purchase, make sure your plan covers pre-existing conditions.
- Wellness and preventive care -Check if the plan includes coverage for routine exams, vaccinations, or screenings. Many insurance plans only cover these services when provided by in-network providers.
- Emergency Room (ER) benefits - Most plans will exclude emergency room visits for non-life-threatening emergencies. Check to see if this is the case for your plan and avoid visiting the ER for minor illnesses such as colds.
2. Do Not Ignore Your Claims After They Are Submitted
A common mistake many policyholders make is assuming that their insurance provider will automatically cover a visit or procedure. However, coverage cannot be guaranteed until a claim is successfully submitted, reviewed, and approved by your insurance provider.
To make sure your claim is handled appropriately, follow these guidelines:
- Understand your plan’s “timely filing period” – Claims must be submitted in a “timely” manner to be considered for coverage. Most plans provide a 90-day window in which a claim must be submitted by you or a medical provider to be eligible for consideration.
- Keep checking for updates after a visit - After a visit, you should expect to receive a bill from the medical provider and an Explanation of Benefits (EOB) from the insurance, which you can expect to be mailed/emailed to you. If you aren’t receiving updates from your doctor and/or insurance provider, DO NOT assume everything is taken care of. Make sure to follow up with them if you aren’t receiving updates.
3. Understand Your Plan Type and Prior Authorization
In addition to reviewing your general plan benefits, such as exclusions and claims process, you also will want to review two key things:
- Your provider networks and plan type – Your plan will provide access to networks of doctors/medical facilities which are considered “in-network”. Though it’s always suggested to go in network as insurance will cover more towards your expenses, your plan may not cover visits to out of network providers. This will often be determined by the classification of your plan, which can include:
- PPO – Covers you both in network and out of network
- HMO – Coverage can vary, though out-of-network providers are often excluded
- EPO – Out-of-network providers are excluded, except in emergency cases
- Pre-authorization – Plans may require the medical provider to get authorization for certain medical services before you go in for them. If your plan does require pre-authorization, make sure to let your medical provider know so they can contact your insurance prior.
My Claim Was Denied – What Should I Do?
Even if you follow the tips above and prepare thoroughly, claim denials are sometimes unavoidable – but don’t panic. You’ll always have the option to appeal an insurance claim.
Errors do occur with claims processing – with reasons varying from providers coding a service incorrectly, not submitting the sufficient documentation or the insurance making an oversight on benefits. Appeals processes vary depending on insurance, but a few things you should do before you begin:
- Understand why your claim was denied – Your first step before you submit an appeal is to review the Explanation of Benefits and confirm the reason for denial. Sometimes it can be due to an error from the provider/insurance, but it also can sometimes be something on your end which can be resolved with you providing additional information.
- Get supporting documentation for your appeal -For an appeal to be successful, you will need to show proof that an error was made that caused the denial so you may need to request supporting documentation from your provider depending on the situation.
- Stay persistent – Appeals processing is often reviewed manually, so it can take a lot longer than the traditional claims process. Make sure to keep following up with your insurance and don’t get discouraged – a lot of appeals do get approved.
How Can I Pay My Medical Bills If My Appeal Is Denied?
If your claim remains denied even after an appeal, you still have options:
- Self-pay or uninsured discounts -Many healthcare providers offer discounts to patients who pay out of pocket, especially if you don’t have insurance or if your claim was denied. Ask to see what options they provide.
- Installment payment plans - If the bill is too large to pay all at once, many medical providers are willing to set up installment payment plans, allowing you to pay the bill over time. Be sure to ask about interest rates or fees that may be associated with this.
- Seek financial assistance - Some hospitals and healthcare providers have financial assistance programs or charity care, particularly for patients with limited income. You may need to provide proof of income or financial hardship to qualify.
- Consider medical debt negotiation - In some cases, you can negotiate your medical bills with your healthcare provider or a third-party medical debt negotiator. This could result in reduced fees or a settlement that’s more manageable.
We hope this article provided you with some helpful information to help stay protected in the future. If you’re an international student looking for insurance, ISO offers plans for all US visa statuses starting as low as $31/month. Our plans have online claims processing and industry-leading customer service to help you with any claims inquiries you may have!
About ISO Student Health Insurance
Founded in 1958, ISO prides itself on being the leader in providing international students with affordable insurance plans. Administered by former and current international students, we are able to assist our member with multilingual customer service in Chinese, Hindi, Spanish, and more. ISO serves over 3,200 schools/colleges and more than 150,000 insured students every year.
For more information, please visit www.isoa.org and connect with us on Facebook, Instagram, WeChat, WhatsApp, and LinkedIn.