Don’s Drafts
Don Groves
Call it the Patient Protection and Affordable Care Act or Obamacare, either way since its inception there’s one thing has been little discussed in the health insurance reform debate: getting what you pay for.
Sure, the aim of the PPACA is to protect patients and make health care affordable, which in theory seems plausible. It all sounds nice on paper, as any health insurance policy does, but what hasn’t been talked about is how difficult many health insurance providers make it for the individual when it comes to actually collecting on a claim.
Health insurance providers use a variety of ways to deny legitimate claims made by their customers. “Lack of medical necessity,” “non participating provider,” “lack of referral/authorization,” “claim not billed on time,” “incorrect diagnosis/procedure code,” “lack of provider number,” “non covered benefit,” “lack of information” — any of these could appear on an “Explanations of Benefits” notice sent by health insurance companies send to customers after they’ve made a claim.
It’s disheartening to discover a claim submitted to a health insurer is denied. It’s downright frustrating when such a denial comes after speaking with a health insurer to make sure a procedure will be covered beforehand, especially when one realizes the cost of the health care bill could easily be paid for if those monthly health insurance premiums didn’t have to be made.
If one is persistent — and fortunate — an appeal can be filed and the health insurer’s denial is overturned but often it requires more than one appeal. Far too often an appeal brings a new reason for why a claim is denied and the process begins anew.
If the claim is ultimately denied, one is now left paying both the medical bill and for the health insurance at the same time. If this isn’t too great a financial burden, well, that’s fortunate. But many can’t afford both, just take a look at the number of the civil cases in the county courthouse.
The U.S. Supreme Court just heard arguments about the Affordable Care Act. The justices are expected to decide by June whether or not to keep all, part or none of the PPACA. No matter which way their decision goes, health insurers need to not only make health care affordable for themselves but also their customers.
Until health insurers stop stonewalling when legitimate claims are made and simplify the claim process, health care will never be truly affordable to those insured.
Publisher Don Groves can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
