While no one likes to pay for health insurance, it is generally agreed to be a necessity due to not only state laws, but the simple costs of treatment. Making sure that the policy you have in place will cover your needs – both for routine treatments and unexpected calamities – is essential in being able to feel some measure of peace and security when it comes to your health care situation. For many Americans, however, it is not the finding and purchasing of health care insurance that result in the most stress, but the claims process itself. Many families are concerned that their claims will be denied or that they will be told their expenses are unreasonable. Often, consumers are unsure about what steps are taken by the insurance company to determine if their claim is reasonable. One step that most people do not know about is claims reviews.

Claims reviews are used by the insurance company to evaluate the validity and cost of any claim made by a client. While not every claim will be subject to review – each health insurance company will have its own policies and procedures – those that are will be carefully scrutinized. The company will look at things including if the procedure was necessary, where it was performed, and what its overall cost was. They may call the care provider or even their insured for more information, which makes many consumers nervous. The key if a claims review occurs is to remain calm and understand that the company is simply doing what it considers to be necessary. Tell the truth, be upfront, and the claim should ideally be paid. In some cases, only a portion of the claim will be paid, and it will on rare occasions be rejected. If this happens, consumers can appeal to an appeal board for a second ruling, and may have the claims review overturned.

The purpose of these reviews is not only to “check up” on client spending, but to keep the cost of insurance reasonable. The fewer claims that are paid out by the insurance company and the lower monthly premiums will be for everyone enrolled with the company. If continued high-cost treatments are paid for by the insurer, premiums will increase across the board. While it is true that the company is most certainly trying to save itself money through claims reviews, they have the added benefit of limiting the cost for consumers.

Should a review occur, simply be straightforward and honest, and do not hesitate to ask questions, request paperwork and pursue an appeal if necessary. Claims reviews, while stressful, are an integral part of the insurance process.