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Claims Handling with Health Insurance

16 August, 2018

Agustin Lopez Carrasco, Head of Claim Services, Swiss Insurance Partners AG, Switzerland

For the typical global citizen, obtaining the best possible international medical coverage is of paramount importance. To do so, clients should study the benefits, limits, and assistance provided with the purchase of a specific product, which helps individuals best prepare for when even the most unexpected possibility becomes reality. Truly, the last scenario anyone hopes to find themselves, or their loved ones, in is a life-threatening emergency without access to quality and comprehensive care.

Despite the importance of having health insurance, as an insurance provider we have noticed that members are often not aware of how to use their coverage and, most importantly, they display much uncertainty regarding how to proceed properly through the claims handling process. Of some relief to clients is that procedures for submitting and approving claims are actually quite standardized among health insurance carriers globally, and it is possible to bear in mind some general tips that will mostly work.

Treatments Needing Pre-authorization

For procedures indicated by the insurer as needing preauthorization, it is very important to confirm authorization ahead of treatment in order to secure coverage. Otherwise, some companies reserve their right either not to cover the expenses or to deduct, as a penalty fee, a certain percentage of the cost. It is always advisable to contact your insurance company timeously or as soon as you know you will need such a treatment in order to have sufficient time to proceed with the necessary arrangements. This is in particular reference to pre-scheduled surgeries, ongoing treatments, and physiotherapy cycles or rehabilitation plans, for instance.

In the case of emergencies, it is highly recommended that you contact the insurance company for assistance. If this is not possible, due to the member being in a life-threatening situation, the insurer has to be notified of the incident at the latest 48 hours after the event, either via the member’s relatives or the treating medical center. Generally, insurance companies will request a complete report supplemented with the patient’s medical records, the diagnosis of the condition, and the treatment and/or rehabilitation plan. Additionally, an estimate of the expenses should be provided in order to assess costs. In this regard, it is convenient to sign an authorization form giving express consent to the insurer to request medical information on behalf of a member in case the insurer needs any further details that the individual is not able to provide.

With all this information, the insurance company can assess coverage so that, if granted, and only if the medical center accepts their guarantee of payment, they can settle the expenses directly to the clinic or hospital. An unfortunate, but possible, scenario is if a guarantee of payment is not accepted by the medical facility, in which case the member will have to pay beforehand and request reimbursement afterwards. As the procedure would have been pre-authorized, this process should not be complicated.

Treatments Not Needing Pre-authorization

In the event that treatments do not need pre-authorization, the pay-and-claim procedure applies, which is the case for most outpatient routine visits, laboratory tests, occasional consultations that do not respond to ongoing treatment, an emergency, or a programmed surgery. Members should pay the expenses of treatment and claim these back from the insurance company.

To do this, members should provide the insurance company with all invoices and receipts of payment and a diagnosis for each treatment. If the diagnosis is not specified in the bill itself, then a report drafted by the physician is necessary. For pharmaceutical expenses, prescriptions and receipts of payment need to be submitted. Lastly, a conveniently signed claim form clearly displaying the member’s bank details should be submitted to your insurer for transferring the reimbursement.

The above, and relatively simple, steps are normally adequate to ensure a swift claims handling process, a convenient relief for today’s time-constrained global citizen.

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