Hospital Claims Procedures: In-Network and Out-of-Network Explained
One of the most dreaded situations expats living abroad face is the sometimes complex set of procedures when it comes to hospital claims. This can be incredibly stressful if you live in a country where the English language is not very common or when you are being admitted in haste. While we hope you won’t have to go through this, knowing what to expect in advance can save you much worry. We explain below the typical hospital claims procedures and discuss the most common reasons for claims refusals to watch out for.
What Happens When You Submit a Hospital Claim
International health insurance policies with hospital coverage often have direct-billing agreements with many hospitals. Because of the direct billing agreement, the claims process is almost non-existent as all administration occurs between the insurance company and hospital directly. In that scenario, you do not need to pay upfront for the medical procedures (up to your policy limits).
In-network Hospitalization Claim Process
Here’s a rundown of how easy and straightforward it is to attend a hospital that has a direct-billing agreement with your insurance company.
Before hospital admission: Meet with a specialist in the hospital or your insurer. They will help you obtain the Pre-authorization Letter for your hospital stay.
A pre-authorization letter is a document confirming the insurer will cover the treatments’ costs. Hospitals usually require these before admission. This is also a guarantee that you get reimbursed. If insurers pay the hospital via a direct-billing agreement, such a letter is called the Guarantee of Payment letter (GOP).
During admission: Show your medical card, approval documents (if any), and hospital admission letter. You should not need to pay a hospital deposit.
Before leaving the hospital: If your hospital bill is within your policy limit, all you have to do is sign the hospital bill granting the hospital permission to bill your insurance. You will not need to pay for the treatment upfront but keep this document as your reference. If your hospital bill is higher than your policy limits, you will have to pay the remaining balance out-of-pocket.
Before selecting an international insurance plan, we recommend that our clients carefully study the list of in-network doctors in your area – so that when you require medical care, you can choose to go to an in-network hospital to avoid paying large medical bills upfront.
Out-of-network Hospitalization Claim Process
Sometimes clients decide to use out-of-network hospitals because they want to see a specific specialist or the treatment will be cheaper than in the in-network hospital. Other times, if you are in an accident, you will go to the nearest hospital and have no say where you will receive your medical care. Whatever the reason, you can claim the money back as per your policy details; however, the claiming process is slightly different.
Before hospital admission: Contact your insurer and obtain the pre-authorization form. If you are directed to the hospital from a place of accident or can’t wait for a Pre-authorization letter, start at point 2.
During admission: Show your medical card, the approval documents, and hospital admission letter, if any. With the Pre-authorization letter issued, usually, no hospital deposit is needed. If you don’t have a pre-authorization letter, you will be asked to pay a deposit.
Before leaving the hospital: Sign the hospital claims form and pay the medical bill.
After leaving the hospital: Submit a claim form and all other necessary documents within 90 days after discharge from the hospital to your insurance company. Some insurers will notify you between 5 – 7 working days (or sometimes longer) about the result of your claim.
As you can see, the hospitalization claims process with-out-of network hospitals is a bit more complicated and requires you to fill in and obtain more documents to make the claiming process possible. Below is a list of the most common hospitalization claims documents to be aware of.
Hospitalization claims documents
- Hospitalization claims form.
- Hospital receipts with a breakdown of charges.
- Medical reports. Sometimes insurance companies require detailed medical information with proof of diagnosis filled out by the attending doctor.
- Identity card copy of the policyholder.
In some instances, insurers can request additional documents to process your hospital claim.
- Supplemental hospitalization claims documents.
- Referral letters for specialist doctor’s consultation.
- Copy of police report or traffic accident report (if you were involved in an accident).
- Copies of diagnostic/ laboratory tests report or operating theatre summary.
- A pre-authorization letter, sometimes also called a Treatment Guarantee.
Why Would an Insurer Refuse to Issue a Pre-authorization Letter/ Guarantee of Payment?
Insurers have the right not to issue you a Pre-authorization letter/Guarantee of Payment. In most cases, it is linked to specific conditions in your policy or the type of medical treatment you are requesting the Pre-authorization letter for. Below is a list of the most common reasons why insurers would decline you a GOPs.
- The procedure you seek GOP for relates to an excluded condition (e.g. pre-existing condition, substance addiction, maternity treatment).
- You have not reached your deductible yet.
- The procedure is deemed medically unnecessary (e.g. cosmetic surgery).
- The policyholder has already reached its maximum annual benefits for the treatment in question.
If you have a scheduled treatment, you should take time ahead of the procedure to secure a Pre-authorization letter. Work with your primary doctor and hospital to produce supporting documents to make the issuance of the Pre-authorization letters more likely. If the medical treatment can wait, you can opt to do it in your next policy year to ensure you have not exceeded your policy limits.
What if Your Hospital Claim is Rejected?
What can you do if your medical hospitalization claims get rejected? Perhaps you required urgent medical care, and there was no time to get a GOP or Pre-authorization letter.
Below you can find the most common reasons why insurance companies reject hospitalization claims:
- Incomplete or inaccurate insurance claims information.
- Lack of prior pre-authorization.
- Incomplete or inaccurate medical records to support the claim.
- Diagnosis and procedure coding errors and omissions.
- Insufficient medical necessity.
- Copay or deductible amounts not reached.
- Policy limits have been reached.
The human errors and lack of individual documents can be relatively-easily solved; however, it will take lots of effort and time. If your hospital claim is rejected, you can always resubmit your claim.
From our experience in advising international citizens, securing a policy with an established international insurance company gives you access to a broader selection of in-network hospitals and clinics. Then you will not have to deal with hospital insurance claims. Contact us to receive a free quote and detailed information about the health insurance plans we offer, hospitals’ networks, and overall policies’ benefits and limits.
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Written by Joe Cronin. Joe Cronin is the Founder and President of International Citizens Insurance. He is an authority in the areas of global health and international insurance, with specific expertise in advising individuals and groups on international health insurance plans. Follow him @Joe_Cronin_Jr