How it Works Health Insurance Reimbursement?

How Health Insurance Reimbursement Works

As many providers do not adjust their fees, this creates a crisis between doctors and health plans.

Imagine the following situation: you've been seeing the same doctor for years, but you had to change because he no longer accepts your health insurance or because you had to switch providers. This is exactly the kind of situation that reimbursement was created for.

National Supplementary Health Agency (ANS)

Although many people have heard about it, they may not know exactly how it works. It's important to note that each carrier has its own refund policy, but there are some common rules that have been established by National Supplementary Health Agency (ANS).

Therefore, we will explain how to request it, in which situations, and how health plan reimbursement works.

In which cases is the consumer entitled to a refund from the health plan?

Health plans cover procedures performed within their accredited network within their coverage area, and this network must provide care to the patient within the timeframe established by the ANS.

For elective services that are not emergencies or do not meet the criteria, it is not possible to request reimbursement from health plans.

Refunds may occur in the following situations:

Full refund in case of use of services outside the partner network

Let's say you want to see a gynecologist in your accredited network, but you're unable to get an appointment within 14 days (the maximum timeframe established by the ANS). If this happens, you can consult with a doctor of your choice and then request a full refund.

However, if the plan is able to cover your needs within the timeframe and you still prefer to consult a specialist outside the accredited network, the reimbursement amount will only be that established in the contract, and may not be full.

Absence of accredited person in the beneficiary's municipality

In cases where there is no accredited provider in your Municipality, but it is necessary for the beneficiary to carry out a consultation or procedure, the operator must be responsible for the transportation expenses, when moving the beneficiary to the nearest accredited provider.

However, if there is no accredited provider nearby, the costs of private care will be the responsibility of the operator.

Likewise, if there is no specialty in the accredited network, the operator must reimburse the beneficiary.

Urgent or emergency cases

The provider must reimburse the beneficiary in full when it refuses to cover urgent or emergency treatment that is part of the coverage or does not comply with the maximum treatment timeframe. This is because it did not follow the contract of the relationship. consumption.

However, some judges may only grant partial reimbursement because the health plan has agreements with accredited hospitals and pays a lower premium. Therefore, contact a lawyer who specializes in health plans to obtain a full reimbursement.

How do I request a refund?

Requesting a refund is quite simple. The first step is to contact your provider and submit your request within the timeframe established by your plan (usually 30 days).

To apply, you'll need to have some documents on hand that prove the doctor or hospital provided the service. These include:

• Invoice: containing the amounts charged for the service, materials and medications, and the doctor's fee.
• Justification for granting the refund.

Other documents, such as a medical report, may be required. This will vary depending on the carrier's reimbursement policy.

What is the refund amount and what is the payment deadline?

Typically, the amount is equivalent to the amount the provider pays for the health plan's professionals. Therefore, if you spend more on medical expenses than the plan covers for care within the accredited network, you'll likely lose out.

Therefore, payment must be made within a maximum period of 30 days after delivery of the documentation.

However, if there is no contractual provision for reimbursement, the operator must pay the full amount for the service.

What should I do if this refund is not granted?

Some people have already had their refund request denied and, in these cases, the beneficiary must seek a lawyer specialized in the matter to obtain compensation for moral damages and material damages in court.

It's important for you to know that reimbursement rules apply to both old and new plans, as health plan contracts are constantly renewed and new laws that come into effect after the contract is signed also apply to them.