By Dez Duran-Lamanilao

Purchasing a health insurance may prove to be one of the best decisions you will make in your life. But what comes next after you get a copy of your plan? While no one wants to undergo the tedious and stressful process of making a claim, knowing how the process begins and ends will give you a heads up on what to expect when something unfortunate happens.

The medical claims process’ key players are the healthcare provider, the insurance company, and the policyholder. Before undergoing a certain treatment or procedure, you will be asked by your healthcare provider to submit your insurance information, so the medical biller and coder can create your record for submission to your insurance provider for claims purposes. The final decision will rest on your insurance provider. They can do any of the following:

  1. Approve all your medical expenses and pay for the bill. This is the ideal scenario. However, bear in mind that the complexities of a policy sometimes make it harder for the policyholder to claim in full all medical expenses.
  2. Deny the claim because of a billing error or wrong patient information and return it to the healthcare provider for correction.
  3. Reject the claim because the treatment is not covered within your purchased health plan. Or you are dealing with an out-of-network provider, which your insurance does not allow. You will then be expected to pay in full all expenses that you have incurred.

The last scenario defeats the idea of purchasing a medical insurance. To avoid this incident from happening, you should first and foremost know your health plan with regard to payouts, pre-authorization, and dedutibles and due dates, among many others, and confirm with your medical provider how they intend to collect.

Finally, amidst the chaos, remember to review your bill with the Explanation of Benefits (EOB) before proceeding. It takes less time to do so than having to undergo the tedious process of making an appeal, which in most cases, may just lead to defeat and inconvenience on your part.