Health Insurance Limitations

Health insurance often requires a mountain of paperwork that has a lot of fine print. Unfortunately, this means that few people read their plans thoroughly nor do they fully understand what their plan covers or does not cover. Here are some common limitations in health insurance coverage that you should know.

Some of the most shocking health insurance limitations are found in the the fine print holes in the insurance policy. For instance, many people have found that their health insurance did not cover a routine or necessary medical procedure because they did not receive an authorization code prior to the procedure or the hospital did not correctly fill out the paperwork. Your medical claim can be denied simply because the hospital used odd codes for your treatment. While any claims denied by the insurance company can be disputed, this process is not only tedious, but time-consuming and draining, especially for someone who is already ill. There is also little success in winning disputed claims, which makes this option rather limiting.

Another surprising health insurance limitation happens more often than people realize. Imagine this situation: you are diagnosed with a medical condition and need an operation. You research surgeons and hospitals within your plan. You understand your plan’s coverage of hospital care. You have your operation and then you find a massive medical bill in the mail. Apparently your health insurance did not cover the anesthesiologist or other specialists that may have consulted in your operation. Thus, you have to pay these specialists for their services, even though you were under the impression that your plan would cover these costs associated with the surgery. Such a bill can be in the thousands of dollars, and there is little you can do to dispute the charges. The only way to avoid these charges is to make sure that you ask before the operation who will be involved and ensure that they are covered in your health insurance plans.

Other limitations are put on a number of treatments. For instance, you may need physical therapy or visits to a psychiatrist. Many health insurance plans will put a limit on the number of covered visits for such medical treatment. Without realizing it, you may surpass the maximum visits allowed by your health insurance and end up racking up huge bills.

Many people think that buying health insurance will cover them medically, but this is only correct to a point. When securing insurance, you should read through your health insurance package carefully, and when you are about to undergo any expensive medical procedure, be sure to consult your health insurance plan first.

Avoiding Insurance Fraud

Everyone knows that the health insurance industry is continually raising monthly premiums, and many feel this is unjust to you as the consumer. However, the health insurance industry has had to fight increasing health insurance fraud. The amount of money spent on investigating and prosecuting fraud is then passed on to policyholders. Many people do not understand what health insurance fraud entails, though. With reports estimating health insurance fraud is a $30 billion to over $100 billion industry per year, the topic should not be taken lightly. Every health insurance policyholder should understand what health insurance fraud is and its consequences. By doing so, you are more able to recognize and fight fraud.

Health insurance fraud is typically defined as intentionally deceiving, misrepresenting, or concealing information to receive benefits from the insurance company. Essentially this means that you assert that you paid for certain medical procedures or expenses out-of-pocket which you have not actually received, and you are submitting claims to the insurance company to receive reimbursement. Another example of member fraud is to conceal pre-existing conditions or to alter medical documents so that non-policyholders or ineligible members receive medical benefits under your policy. Perhaps your sister does not have insurance and needs medical attention. Having her use your name and policy to cover the expenses is health insurance fraud. While you may think that this is a small issue in comparison to your sister receiving treatment, it is actually very serious to your health insurance company and industry, and will result in fines and possible imprisonment if your are caught.

Not only policyholders commit fraud, but providers (physicians, hospitals, etc.) do as well. Since physicians and hospitals bill the insurance company for services they provide for you, they are also receiving reimbursement from the insurance company. When providers commit fraud, they may be billing the insurance company at higher rates for services rendered or they may bill for services you never received. In these cases, you will probably be asked to cooperate in the insurance company’s investigation.

Another type of health insurance fraud that has developed recently targets the policyholder more than the insurance company. Schemes have developed where fake insurance companies or agents sign unsuspecting customers for coverage at surprisingly low premium rates. They often act much like a regular insurance company for the first few months, paying for smaller medical claims like physicians visits. But once you have a more serious medical condition that needs treatment, the insurance company will disappear – along with the money you have been paying in premiums.

The rule with health insurance fraud is much like that of any other scam: if a deal seems too good to be true, just remember – it probably is. Remember to be honest in your dealings with health insurance companies and expect the same in the return from these companies, as well as your health care providers. Stay legal to avoid fines and prison and to continue receiving health insurance coverage.