According to the Centers for Medicare and Medicaid Services (CMS), in 2020, total health spending in the U.S. reached $4.1 trillion, or about $12,530 per person. It is due to the high medical bills. However, if you have health insurance, you don’t have to worry much about the expenses, as you can get a part of your expenses from the insurance company.

The best way to get paid for medical expenses is to submit insurance reimbursement claims. You can do this by filing a claim with your insurance company. However, there are some steps that you need to follow for them to evaluate and approve your claim.

What Is a Reimbursement Claim?

Insurance reimbursement allows you to claim money from your insurer after a medical expense. This is usually done when the claimant has paid for their medical expenses, not their insurance company.

The reimbursement process can be challenging, but technology can help. You can use applications that help you submit forms, track your application's status, and communicate with your insurance company. There are many such reimbursement applications.

You can use an insurance reimbursement app to help you file a claim for reimbursement of out-of-network medical expenses. Such apps allow you to track costs and ensure you receive the maximum amount covered by your insurance.

The amount of money that can be claimed will depend on your policy and the type of treatment it covers. Generally speaking, reimbursement claims should be filed within 30 days of receiving treatment or paying out-of-pocket for any medical services not covered by your health care or provider network plan.

This can also be the other way around. Sometimes, even healthcare providers might have to claim reimbursement. For example, during the pandemic, health providers treating the uninsured got reimbursement from the government programs, such as the American Rescue Plan (ARP) Act, which provided a $4.8 billion package.

Inform the Insurance Company

If you have an insurance policy, inform the insurance company of your hospitalization. Some companies will send a claim form to your home address, while others will allow you to submit the claim online. The best way to ensure that your claim gets processed quickly is by communicating with them directly.

If you don't know where to start or what information needs to be included in your submission, call their customer service line and ask for help. They can answer any questions you may have about submitting a reimbursement request and filing a complaint against them if they refuse payment on your behalf. Additionally, they might be able to point out how long it can take before getting reimbursed.

Find the Documentation That You Need

You need to gather the following documents to submit your insurance reimbursement claim:

  • Documentation of the treatment received, such as a bill or explanation of benefits (EOB). This can be a photocopy, fax, or electronic copy. If you don't have one, contact your doctor's office and ask them for one.
  • Documentation of the diagnosis, if available from your doctor's office or from an examination report done by another health care professional like a psychologist or psychiatrist who treated you during this period.
  • Documentation of the cost of treatment and follow-up care. It should include direct medical costs (such as medications and lab tests) and indirect costs (such as transportation expenses).

Fill Out the Claim Form Completely

Filling out the claim form appropriately is crucial in determining whether your claim will be approved or rejected. Here are some tips for filling out the claim form:

  • Make sure you fill out the claim form completely.
  • Use the claim form as a guide, but include all of your information and be sure to answer all questions.
  • Include your name, address, and contact information accurately in the form.
  • Sign and date the form before sending it in with other required paperwork or documents.

Submit the Supporting Documents

You will need to submit supporting documents containing the details of the treatment received. This should include the following:

  • The dates of treatment, including the date of admission and discharge
  • The name of the hospital or clinic where you were treated
  • Your name, address, and telephone number
  • The type and quantity of drugs prescribed by the doctor
  • A doctor's prescription for obtaining medication from a pharmacy
  • A copy of your bill from the pharmacy showing the total amount paid for prescribed drugs

Make sure you keep copies of these documents if they are lost during shipping or transit back to your home address.

The Company Will Evaluate Your Claim Request and Initiate Reimbursement Accordingly

The company will evaluate your claim request and initiate reimbursement accordingly. They may contact you if they need more information, ask you to send them more documentation, or ask you to send them a copy of your receipts.

When you submit your insurance reimbursement claim, there is a chance it might be denied. The Kaiser Family Foundation found that in 2020, on average, 18% of claims by in-network providers were denied, but some plans denied as many as 80% of claims. 

The most common reason for a denial is that the patient did not have coverage from the carrier or that they did not fill out the claim form correctly. Other reasons include the following:

  • The treatment occurred outside of your policy's coverage area
  • You did not provide all of the necessary documents with your claim
  • Your insurance company has not approved your provider

If you are dissatisfied with your health insurer's decision on a claim, you can appeal the decision and have it reviewed by an independent third party.

Conclusion

You should always take care of your health and try to get the best treatment you can afford. Forty-two percent of Americans reported problems paying medical bills or being in debt due to medical bills in the Commonwealth Fund Biennial Health Insurance Survey. 

If the treatment does not fall under the health insurance policy, you can use reimbursement claims to get some money back from the insurance companies.

Insurance companies process reimbursement claims on a case-by-case basis. Still, they usually require supporting documentation and submitting an application form with all necessary details, like the date of treatment received, the amount paid by the patient, etc.