By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
Watch the video: https://youtu.be/YHNWs-iQ_6o
August 8, 2024
The term “Not Covered” is rampant in healthcare, on every Explanation Of Benefit your insurance issues when processing a medical claim, on denied authorization requests, on appeal decision letters.
What does it mean exactly, and how to overturn it? Let’s explore.
A. What does it mean?
A medical service, Rx, treatment, item, device, procedure can be considered “not covered” under the terms of your policy for several reasons:
1. Not a benefit at all
· the item or service is specifically listed under “exclusions”. For example: infertility treatments, acupuncture, cosmetic surgery
· the type of service is not part of the medical policy (i.e vision or dental services)
· the service is the result of a work-related injury, car accident or other circumstance which is the responsibility of another type of insurance (i.e. Workers’ Comp)
2. Deemed “experimental”, “investigational” or “off-label”
· It is not clinically appropriate, or considered “standard of care” for this diagnosis
· It is not FDA-approved (or not for this diagnosis)
· It is not recognized as being “safe and effective” through studies, trials, peer-reviewed article sin medical journals, or by the medical profession at large
3. “Invalid” circumstances
· Prior required authorization was either not requested at all or denied
· Coding is incorrect or unjustified. For example, the diagnosis code and procedure code are not compatible
· Info or documentation was missing or not provided when requested, such as medical records, test results, scan reports
4. Policy limits
· Service is only covered for a certain age range or minimum (i.e colonoscopy after age 60 if no risk factor, mammogram after age 40 if no risk factor)
· Limited number of visits or same service per year: for example: Physical Therapy sessions, ABA therapy (for autism), screenings (yearly physical, mammogram, some scans etc)
. some procedures or services may have a maximum payable $ amount (i.e $ 500.00 for ambulance rides, or $ 30,000.00 for a hip replacement)
· Geographical restrictions: some plans may limit in-person services to your State of residence or nearby Zip codes (except in case of emergency)
5. Out Of Network (“OON”)
· Some plans do not provide coverage (and therefore payment) for non-emergency services when the provider is not contracted or “in network”. This is especially the case with EPO and HMO plans.
· “NOT COVERED” ON EXPLANATIONS OF BENEFITS FOR OON CLAIMS INDICATE THE PORTION OF THE BILLED AMOUNT WHICH IS DEEMED OVER “FAIR VALUE” BY YOUR INSURANCE
B. Your wallet
1. If “in network”:
· The “not covered” column of your Explanation Of Benefit will (should!) always be $0.00
· The portion of the amount billed which exceeds the contracted rate between that provider and your plan will be a write off for the provider. You do NOT owe this amount, it is your discount.
2. If “out of network”:
· the term “not covered” refers to the $ amount between the amount billed by the medical provider and what your insurance deems it a fair value for the service (“allowance”).
· You are responsible for this amount
· BUT ONLY THE AMOUNT LISTED AS “ALLOWANCE” WILL BE CREDITED TOWARD YOUR OON YEARLY SAHRE OF COST NOT THE TOTAL AMOUNT YOU OWE TO THE PROVIDER.
· Example: service was billed $ 1,000.00. insurance deems $ 250.00 to be “fair value” or “allowance”. This amount is credited to your yearly OON share of cost. You are responsible for $ 750.00 (“not covered” in the allowance) and any amount up to $250.00 not paid by your insurance (if applied toward your deductible for example)
· In a word, you are responsible for the full amount billed minus whatever your insurance may pay. You receive no discount. The provider does not have to write any amount off.
C. Solutions
1. Provider Responsibility
· Provider must correct their coding error, submit a “corrected” claim to the insurance to fix a coding error problem
· Provider must provider the insurance with the request medical records to get an approval or release a payment
· Did they give you advance written notice that a service would not be covered? If not, why not? Can this error on their part result in a price reduction for you?
2. Insurance processing error
· If you or the provider see an obvious processing error (AI processing systems are terrible these days…) , contacting a representative should fix the issue.
· Filing an appeal may be necessary, if there is specific clinical, legal or other evidence justifying the coverage (i.e emergency services, authorization in place, recently FDA-approved, must be covered by law, medical policy not up to date, deemed “safe and effective” by medical organizations, OON claim must be paid at higher rate per No Surprise Act, …)
3. Go higher
· If you plan is administered by the dept of insurance in your State, request an extension or exception (for example to raise a yearly limit, or get coverage for out of state services)
· Contact your HR dept or Upper Management if your plan is Self-funded, and your employer determines what is covered
· Document the medical need and circumstances: no in network or in state provider is experienced enough, the only super-specialist for your rare disease is out of network, emergency conditions, your autistic child has been prescribed more ABA visits than the policy allows, the policy is too restrictive as established under the Standard of Care in the US
· Exceptions are often granted if requested, and when documented as justified
In Conclusion:
“Not covered” services always result in a statement with your name on it.
But it does not mean you actually owe it!
Finding out why something is “not covered” is the first step to fixing what is often an easy issue to resolve.
Patients have rights, resources and can often save $ with a little detective work and call or appeal.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024
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