Health insurance providers, both public and private, are looking for ways to cut spending. One of their strategies is to deny claims for treatments they deem unnecessary. The effectiveness-testing studies receiving funding in Congress’ healthcare reform bill is a case in point. While that’s a laudable goal, what if your doctor recommends an unusual course treatment?
Experts recommend that you never tell your health insurance plan that you are receiving an “investigational” or “experimental treatment; or if you are enrolled in a clinical trial. These phrases are codewords that make insurers more likely to look closer and reject your claims. First off, health insurance plans will cover treatment your physician considers medically necessary. When it comes to insurance, you obviously shouldn’t lie (that could lead to cancellation of your policy, leaving you uninsured); but you also shouldn’t give more information than is specifically asked for.
You may even be wrong about the experimental status of the procedure. Some procedures aren’t typically used, but are proven medically effective nonetheless. In that case, health insurance plans should cover it. Check with your doctor, even if he or she used wording such as wanting to “experiment with a treatment”. Don’t let semantics cost you!