The Role of Medical Review Companies in Your Insurance Claims: Your Health, Coverage, and Warranty
A medical review company provides more than one second opinion. The unbiased nature of a medical review company is critical not only to the bottom dollar, but to the bottom line as well. Too often, patients think they are just numbers in a file or bits of information in a computer program. The maligned image of automatic claim denial by an insurance company without truly understanding the patient’s need contributes to consumer dissatisfaction and frustration.
What does it have to do with you?
Patients are people and when they need medical care, they don’t want to read the fine print or a medical dictionary, they just want their claims covered. Most of the time, they are unlikely to realize that your insurance claim went through the health insurance review process of an Insurance Review Organization. In fact, they probably just fill out the forms, give the receptionist their insurance card, and sign the necessary authorization forms.
One of the most common complaints about the need for medical care is the cost closely followed by the complications of paperwork generated through authorization forms, claim forms and more. An insurance review organization is an intermediary company to which insurance companies can outsource your claims to accurately determine medical and insurance coverage the validity of a claim submitted by someone insured by their company.
Your health matters
Insurance companies that deny a claim are often portrayed as heartless or more interested in the bottom dollar than showing compassion. This perception only increases when an insurance company rejects a claim based on anecdotal evidence. When a claim goes through the insurance review process of a medical review company, it will not be rejected or denied based on anecdotal evidence.
For example, a patient suffers from shoulder, back and neck pain, as well as eczema and grooves on the bra strap. His medical history indicates years of chiropractic treatment, as well as advice on non-steroidal anti-inflammatory drugs (i.e. Tylenol, Advil) and specialized support bras used to support a 34DD frame and all with no success. Excessively large breasts can cause many of the symptoms noted in a woman’s medical history.
The doctor recommended a breast reduction procedure to alleviate the problem and symptoms.
Your coverage matters
When the claim is submitted to the insurance company, the policy may not cover elective cosmetic procedures. Many policies do not. Claims administrators lacking medical experience will often compare a procedure request to a list of approved procedures. If cosmetic procedures are not covered, the claim will likely be denied. The patient has to choose to pay for the procedure out of pocket or continue to suffer.
If the claim is sent to an outside intermediary, such as a medical review company, the response will be different. The medical review company has access to a wealth of medical specialists and insurance experts. Medical specialists will review the patient’s medical history and the doctor’s recommendations. When your record is reviewed, the outside specialist will consider your history of shoulder, neck, and back pain. They will write down visits to a chiropractor and other relevant symptoms.
If the specialist physician agrees with the patient’s physician that she suffers from macromastia (excessively large breasts), then they will understand that cosmetic breast reduction surgery provides the patient with the best option for patient relief.
Trust matters
The review process can be transparent to patients whose insurance company uses a medical review company; but the effect is profound. Your coverage premiums are likely to be lower. Your medical needs will be addressed. They will not see their health care costs rise due to underwriting unnecessary procedures. When it comes down to it, a medical review company gives patients the confidence that their medical and insurance needs will be met. They will not have to suffer misery unnecessarily or face collections for a growing debt.
No Comment