Let’s sidestep that sticky issue for today, and focus on a practical matter. While it doesn’t happen very often, you need to know what you should do when your medical insurance company doesn’t want to pay for a particular claim.

The important thing is to act

Most folks just accept what the insurance company tells them. If the provider says “no, we won’t pay for that,” they accept their fate, throw their hands up in the air and say, “poor me.”

That is a big mistake.

You need to follow up. You can take just a few simple steps to get the claim reconsidered. In a good number of cases, simply doing this is enough to get the company to change their mind.

Identify the problem

If a claim is denied, the insurance company will usually give you a reason. In many cases, they will claim that the particular procedure, test or other medical service that you need isn’t covered by your policy.

If that’s the case, you need to read the policy. Look to see specifically what it is they’re referring to, so that you can identify where the problem is. Some things, like vision, dental and even pregnancy are just excluded from some policies. If that’s the case, you really don’t have much of a leg to stand on.

Human error

In other cases, though, the problem isn’t that you don’t have coverage. The problem is that there’s been a mistake somewhere. It might be that the health care provider entered the wrong billing code for your condition or treatment. It could be that someone at the insurance company made a mistake in reading the claim. There are plenty of points of failure, and working with your doctor’s office and the insurance company closely is the way to get those fixed.

While you can’t guarantee that a claim will be paid just because you ask for it to be reconsidered, you can guarantee that it won’t be paid if you don’t follow up.

Photo via aigarius

Ellen Hayden, a single mother from Hampton, lost her mother to breast cancer when she was seven years old. She knows that a family history of breast cancer is one of the major risk factors for the disease, and she also knows that regular mammograms are one of the best ways to catch breast cancer while it can still be treated and before it can cause too much damage.

Unfortunately, the United States Preventive Services Task Force made a recommendation recently that suggested women under the age of 50 years old do not need to have routine mammogram screenings. This decision, in turn, is affecting the way that some insurance companies will pay for these kinds of routine screenings.

Hayden’s health care provider recently recommended that Hayden have an MRI. The MRI came following an abnormal result from her annual mammogram exam. Yet, Hayden’s medical insurance plan has decided not to pay for the MRI.

The woman has medical insurance through Blue Cross and Blue Shield of Illinois, as her employer is based in that state. The insurance company denied the MRI payment. A statement from the medical insurance company stated that the denial wasn’t based on the cost of the procedure, but rather on how Hayden’s policy is set up. Hayden’s medical insurance policy requires her to get an approval before having a procedure like an MRI, and Hayden did not follow those procedures.

The company also suggested that perhaps a biopsy or an ultrasound may have been a more appropriate step, rather than jumping to an MRI. An MRI is a much more expensive procedure than the other options.

Hayden’s story is a good example of the frustration that many Americans have with the state of medical insurance in the country. There are many stories like this of medical insurance coverage disputes. Workers, who regularly pay for their insurance premiums, find that the insurers aren’t covering the services that doctors are recommending.

Further complicating the issue is the fact that there is inconsistency from one insurer to another. In addition, insurance rules are based on individual state law, so what happens in one state may be very different than the rules in the next state over.

One aspect of this story is the fact that Hayden didn’t realize the procedure required an approval. She knew her health care provider had recommended and scheduled the test, so she assumed that the proper insurance procedures would be followed. In this case in particular, it is possible that the procedure may have been covered if the proper procedures had been followed.