Anyone who has ever attempted to get approval from a health provider to see a specialist or start on a new medication or treatment knows the overwhelming and frustrating challenges that can be encountered. It may be difficult, for example, for patients suffering chronic pain to obtain coverage for medical or alternative procedures such as acupuncture or guided imagery, or certain types of medications. The purpose of this article is to highlight some important things to know about your health insurance policy, as well as provide some tips for communicating with your insurance representative.
Whether you are requesting information about your current insurance plan or are applying or transferring to a new plan, it is essential to understand the benefits and limitations of your insurance policy. Although there are numerous pieces of information to review and questions to ask your insurance carrier, some of the conflicts, with insurance carriers, that individuals with chronic health problems have shared with me over the years, have led me to highlight a few of the most critical concerns.
Each year your insurance company can make major policy changes. These changes usually commence at the beginning of the calendar year, but occasionally could occur throughout the year. In addition, a specialist previously covered by your health plan that you have been considering making an appointment with could decide to discontinue their contract with the insurance carrier during the year due to a business change in their group practice. If you are considering going to a new physician, always review your insurance plan by checking their web site or by phone to check if this physician is still in your provider network.
One significant area frequently neglected by many people is remembering to keep up to date with your health insurance coverage plan and any policy changes that have taken place from one year to the next. For example, if there are any changes in your marital status, new dependents or any changes made to your plan during open enrollment at your work place, you need to contact your insurance company and ask how you would make these additional changes or revise your current health plan to ensure you will have the coverage you need and want.
In order to be prepared in dealing with health insurance providers, there are a few basic questions that need to be answered.
First, are the current medical providers and the hospital you currently utilize included in your plan’s network?
Second, do you need authorization from your Primary Care Provider to see a specialist?
Third, if you choose a physician outside the provider’s network, will you be covered?
And finally, can you change Primary Care Providers?
In addition, if you need to be admitted to the hospital or go to a clinic for a procedure, always confirm that all of the medical providers [i.e. anesthesiologist, radiologist, hospitalist, specialist…], including the facility is contracted with your health plan. The facility or the individual physicians may have their own billing system. If so, they need to be contracted with your health plan to be considered as an in-network provider.
Six Essential Items When Communicating with the Insurance Company
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Despite the best efforts of most doctors, claims are frequently denied due to information that is inaccurate or missing from your medical forms/bills that are submitted by the doctor’s office to the insurance company. To help avoid unnecessary claim denials, have the following six items available for all written and phone communications, as well as hospital or health related visits. 
