THE PROBLEM:
You've received a bill from your doctor that states you owe for a recent visit. "How can that be," you ask when you call the doctor to inquire. Imagine your surprise when you are informed that the charges for treatment you received were denied because your condition was pre-existing and you are responsible for the charges. Now the ball is in your court and you're not sure why you have insurance after all.
CONFUSED?
If you're confused, don't worry, you're not the only one. Sometimes even doctor's offices and insurance company representatives are not clear on when pre-existing conditions apply. For example, generally the flu should not be considered pre-existing. On the other hand, tonsillitis may be pre-existing, depending on the patient's medical history. Not all medical conditions are subject to pre-existing and that's where the confusion comes in. Sometimes billing and insurance professionals think if someone is in a pre-existing period, then all treatment falls under this exclusion. That is most definitely not the case. Pre-existing only applies to conditions that are basically on-going or recurring, such as arthritis, back problems, circulatory issues, etc. But, plans are prohibited from applying pre-existing to pregnancy, genetic information and certain children.
WHAT'S THE DEAL?
Many insurance plans have a pre-existing period built into their plan design for no more than twelve months or eighteen months for late enrollees. A pre-existing period excludes treatment for any illness or injury, for which diagnosis, care or treatment was recommended or received six months before the start of coverage in a group health plan. When conditions are subject to a pre-existing period, services that were received within the pre-existing period can be denied.
Generally, the first claim of the plan year for a new enrollee is the trigger that generates the insurance company or TPA to send a letter to the patient requesting the contact information for all treating providers for six months prior to the effective date of the coverage. Once the information has been received, the insurance company or TPA will request medical records from each provider listed. When that information is received, the insurance company or TPA reviews the records to determine whether there are any pre-existing conditions. Pre-existing conditions, or lack of, are noted in the insurance company or TPAs files. Then, for the balance of the pre-existing period, each time a claim is processed the pre-existing information is reviewed to determine whether the claim is eligible for payment.
In plain English, this means if you were treated for an on-going or recurring illness prior to enrolling in a new plan, the new plan will not cover treatment for that condition during the pre-existing period. If medical advice, diagnosis, care or treatment was NOT recommended or received in the six months before enrollment into the group health plan, then the prior condition may not be subject to a pre-existing exclusion. But, there is one way to avoid delaying payment of your claim. If you were covered under a previous plan before enrolling in a new group health plan, and there was less than a sixty-three day gap in coverage between the end of the prior plan and enrollment into the new plan, the time you were previously covered can be used to satisfy the pre-existing period in the new plan.
WHAT CAN I DO?
Give the new plan your proof of credible coverage from the prior plan as soon as you have it in order to prevent payment delays. This document, generally called a Certificate of Credible Coverage or HIPAA Certificate is sent to you by the prior insurance plan when you have lost coverage from the prior plan. If you don't have proof of credible coverage, and especially if you haven't received treatment or had a physician recommend treatment, be sure to complete the pre-existing letter you receive from the new insurance plan and get it back to them ASAP so they can note their records accordingly and get your claims paid in a timely manner.
Copyright 2010
About this Author
Author and health insurance professional, Lynne Lucio has been deciphering the medical claims labyrinth for over 20 years assisting the otherwise helpless in the pursuit of covered procedures and accurate and timely claim payments. She is the author of The Insurance Decoder (self-published) which is the culmination of her career in the industry providing the depth and breadth of knowledge of the medical claims process and what it takes to get claims paid correctly. Lynne has shared her expertise with thousands of insurance users by helping them resolve complicated health claims and save thousands of dollars while at the same time showing them how to grab the reins of their health insurance and take full advantage of their insurance benefits. http://www.theinsurancedecoder.com
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