Health Insurance Rules

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that seeks to protect the privacy of health-care data and enforce standards for how health-care providers handle this information.

Because of HIPAA, there are strict rules providing what a healthcare provider can release about you without your consent, so you should be aware of these laws. With that in mind, here are some helpful tips on dealing with insurance companies when filing a claim or discussing your medical history. 

Note: This article does not provide legal advice but rather it offers information to help people who are dealing with insurance companies more easily understand their rights.

When dealing with an insurance company it is best to start with a letter in which you detail the injury you sustained and, if possible, include copies of any medical records related to your injury. (Note: You need not provide a copy of your medical records if you already have a copy from the healthcare provider.) You can request that the insurance company contact you by mail or fax and tell them that they are required by law to exchange information with you before they will be able to finalize your claim. In addition to the letter, keep copies of any medical documentation sent to your health provider curing your injuries. You should also keep copies of correspondence from the insurance company for at least three years. That way if a dispute arises, the insurance company cannot argue that it does not have proof of its denial of your claim.

Do not sign any document or agree to any settlement until you receive a letter in which the insurance company has acknowledged receipt of your documentation and agrees to work with you. Furthermore, never allow an insurance claims representative to review your medical records over the phone or online without your authorization. If they ask for your consent, you do not have to give them permission. The insurance companies are not required to release your medical records.

You should be aware that when an insurance company denies a claim or settles for less than the full value of the injury, they are not obligated to tell you the reason for their denial or settlement. In fact, if they do provide their reason, it is frivolous and those reasons may be illegal. Also, you will not be able to appeal the denial of your claim. If you submit a claim without receiving any notification of denial, you should contact the insurance company in writing and ask that they send you a letter telling you their decision, if applicable. You can also request that the insurance company send a detailed explanation of their decision to deny or settle for less than full value.

You do have some options when dealing with an insurance company. It is important to know that when dealing with an insurance company regarding medical information, there is no law requiring them to provide any information without your consent. In addition, you have the right to take an individual case to court. You can also contact a lawyer for more information about your options.

To get copies of your medical records, you should be prepared to wait several weeks or even a few months. In order to expedite your request, you can call and ask for copies that are being electronically transmitted but this can take a few months.

The following are examples of emails that an insurance company may send regarding HIPAA:

One common clerical error that is often made when insurance companies receive claims is when they mistakenly sent the claim directly to the wrong patient's medical records. If you have been to the doctor or hospital many times, insurers may not notice the mistake until you call them for a claim. They will then ask for your medical records and if they are sent to the wrong person, they will want copies of these records as well. You can get copies of your own medical records by calling the office that treated you and obtaining a copy. You can also request that a notice be sent to all providers of care in an attempt to expedite your request for a copy.

You may also want to speak with your health insurance company about other issues including transfers, cancellations, and discharges related to your healthcare provider. These issues can arise when you have a dispute with your insurance company or health care provider.

If your health insurance company puts a hold on your benefits while they investigate a claim, you have the right to be notified about the investigation. They may also ask you to provide certain documentation from your healthcare provider including diagnosis, ongoing treatment plan, and referrals to specialists. You will also be responsible for submitting all documentation related to an injury or illness as it occurs so that your insurance company can review the information in a timely manner. If your claims are repeatedly being rejected for investigation, this may be a sign that something may not be right.

You may also have the option of providing your health insurance company with a copy of your medical records. Your health insurance company will then be able to contact you if they need any additional information or documentation. You can also ask that a letter be sent to your doctor or hospital concerning the claim. The doctor or hospital may agree to provide their records even if you do not, but you should try to request this in writing even if they agree. If they refuse, it is best not to pursue them in court since they are unlikely to comply with your request for information.

Insurance companies may place holds on patients in order for them to contact their doctors and other healthcare providers about an injury prior to making a decision on their claims. You can ask your doctor to fax or send a letter including your diagnosis, treatment plan, ongoing care, and any additional information. Your doctor can also file for a release in court if you request it. You will need to contact the insurance company and ask that they remove the hold on your benefits.

When you file a claim with an insurance company, you should be prepared to wait several months before you are receiving payment. In order for them to resolve a claim, they have to take at least one look at the information that you provided and it takes time for them to do this. You can send your medical records in order for them to review your case and make a decision.

Many people do not know how to report errors in their medical records. You should file a complaint with the hospital or doctor that treated you as soon as possible. It is recommended that you request copies of all your health records before the appointment so that you have an accurate account of what happened and can submit this to the insurance company if needed.

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Conclusion

As seen in the three examples above, medical information is a key part of an injury claim. You should know as much as you can about your claim before you file it. However, there are many other important factors that could affect the outcome of your claim and you should consult with a lawyer when deciding what to do. A lawyer will be able to tell you if there are any options available to you and advise you on how best to pursue them. If there are none, or if they seem unlikely, going ahead with the claim will help ensure that your rights are protected and that you receive the compensation that is right for your injury.