Archive for April, 2011

PostHeaderIcon Pre existing conditions

Insurance language defines pre existing condition as a symptom, illness or health condition that was known and existed prior to the writing and signing an insurance contract. Health or life insurance policies will typically not cover pre-existing conditions until a specified period of time has elapsed. Depending on federal and state laws pre-existing conditions may not be covered at all.

The Health Insurance Portability and Accountability Act (HIPAA) provide some protection for people in transition, although it doesn’t go far enough.  The HIPAA law allows a 63 day gap between health insurance coverage.  Once the person is without medical insurance over 63 days, they are vulnerable to insurance company searches in to their medical records.

Unfortunately there are a lot of people affected by this unreasonable rule created by the insurance companies.
In a recent case a young woman was hospitalized and one of her old diagnosis was listed on her medical bill.  This code was put on to represent her historical medical condition and had nothing to do with her recent hospitalization.  Unfortunately, this simple coding oversight prompted her insurance company to deny her hospital and all other relevant medical bills.  The denial brought on disbelief, then frustration and anxiety.  Finally a well drafted letter from the treating physician clarified this new medical care need and all her claims got paid.

Another case involves a man who has been out of work for about two years.  His COBRA had run out and he couldn’t afford medical insurance, therefore his coverage gap went over the 63 day threshold.  One month later he finally got a job with medical insurance. Three month later he found himself in emergency surgery.  Unfortunately the surgery was similar in many ways to his previous condition and anatomical location.  Fortunately, the sudden illness was a newly manifested condition; therefore his insurance cannot deny his medical claim.  With that said it does not mean they don’t try.  Several request letters were sent to the patient.  These letters are originating from a third party company and asking for his signature to give authorization to request all his medical records.  Fortunately he was referred to us at MedBillsAssist, before he had signed any authorizations.  Our first action with the client was to acknowledge the request letters, but did not authorized access to his medical record.  It is always a bad idea to permit third party company to start looking through medical documentations.  The reason is simple:  records aren’t always correct. Hospital and physician records are handled by many and the process is error prone.  It is a very good idea for patient to request medical records and review them for accuracy.   According to HIPPA regulations, a patient can request their own medical records simply by signing and dating a request to release.       Once a person satisfied that the documentation is what he/she understands to be true, then it can be forwarded to the third party for review.  If there is an error the patient has a legal right to request correction of that error.  A simple letter to the hospital or physician to modify the medical record should be sufficient.

The Patient Protection and Affordability Care Act prohibited insurers to deny claims for children, except in grandfathered individual health insurance plans, based on pre-existing condition starting last fall.  The same law will apply to adults in 2014; provided the law will not be modified.