I have heard that the health insurance companies make mistakes all the time, but because people don't know how to read the statements consumers are regularly overcharged and don't know it. What questions can I ask my doctor to ensure that treatment will be covered-I heard that the wording a doctor uses can determine if the ins. co. will cover the treatment or not.
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Insurance companies provide a plan document that explains what they will cover. Most people look at what their copays are, but few read into the limitations and exclusions. What the doctor says (via medical records and ICD-9 & CPT coding) DOES determine whether the insurance company will cover the service, but the physician (or his staff) is legally obligated to code for the exact service provided. For example, if your insurance company does not cover a routine eye exam per plan exclusions, and the doctor codes the visit as a routine exam, your claim is DENIED. If the doctor codes the visit as something was medically wrong with your eyes, it might be covered. But, it would be unethical to change a diagnosis just so your insurance company would pay if you were really only there for a routine exam. Bottom line ... understand what your insurance company will cover, and be prepared to follow the rules. PS, it isn't your doctor's job to know what your insurance pays for, it is yours.
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