How do health insurance providers find out your pre-existing condition(s) when you go to get medical attention

Question

If a person has a condition, say a torn rotator cuff, and they wanted insurance because they didn't have a ridiculous amount of money to repair the problem--after getting insurance (or before) and you were to go get your rotator cuff fixed, but you were denied of grounds of "pre-existing condition", how exactly do they know this information. Say a person had lied, and said on their insurance application, "nope, im perfectly healthy", how does insurance companies know if say, this person did go visit a doctor years ago, or had seen someone for their rotator cuff problem (pre-existing condition)...How do insurance companies find pre-existing conditions since all medical information is private--or is it...

Answer 1

Your insurance company has the legal right to request and receive any medical records from your doctor that are relevant to processing your claims.

I saw a guy get busted once because he applied for a policy stating that he had "no previous medical conditions," then ended up having a very expensive knee surgery within a month of when the policy began. When looking at the medical records, there were multiple notations about the knee issue from before he applied for his policy.

The policy was declared invalid. (Since it was obtained via fradulent methods, it was as though the policy never existed.) The insurance company retracted all the payments from all the doctors, hospitals, etc. And the guy became liable for nearly $100K medical bills...all because he lied.

(The sad thing is that disclosing the injury may not have prohibited him from getting coverage...he might have had to pay a higher premium, but it still would have cost him less than the $100K that he ended up owing.)

Answer 2

It's actually easier than you think. First of all, the claim form used by health care professionals (called the HCFA 1500 or CMS 1500) has a block where the first date of diagnosis is entered. If your insurance was effective 8/1/07 and the date of diagnosis is 5/3/07, that's a tipoff that the insurer needs to look into this more closely.

Regardless of what the claim form block says or doesn't say, most insurers will request a copy of the doctor's medical records for all dates of service. If the doctor's notes provide evidence of a pre-existing condition, the insurer can deny the claim; depending on the nature of the misrepresentation made on the application, it could also rescind the coverage (make it as if the policy was never issued).

In some cases, insurers end up requesting records from several health care professionals, so this process can take several months.

To correct answers given by Nancy J and Mbrcatz, the MIB does NOT accept health claim information from doctors OR insurers. It ONLY accepts information disclosed either on an application for insurance or discovered during the underwriting process.

Answer 3

Not all medical information is private. For instance, your insurance company can get medical information from your doctor because they use it for the specific purpose of processing your medical claims. That's completely fair and legal.

Your insurance company can find out about pre-existing conditions a few different ways. First of all, they'll ask you about them on your application. You can say that you're completely healthy, but your insurance company has the right to request medical records from your doctor. The records will show if you've been treated for a condition within a specified period of time.

Secondly, when they get your first claim for a rotator cuff injury, they'll ask AGAIN if you've ever been treated before. Typically, they'll send you a letter. They can also contact the doctor at that time. They'll ask the doctor for the first date of treatment for the rotator cuff problem, and the doctor will tell them.

It's almost impossible to pull something like this over on your insurance company. And it's fraud. If you get caught, not only will you lose your coverage, but you'll have to pay back any claims that were paid under false pretenses by the insurance company.

Answer 4

If you saw the same doctor for the same condition, it will be in your clinic notes. In order to prior-authorize a procedure, the insurance company requires a copy of the clinic notes and a Letter of Medical Necessity from your doctor. Your doctor then sends this information in so the insurance company can review the situation and make a determination on whether or not they are going to cover the procedure or not.

Now, if you don't have proof of prior continuous creditable coverage (a copy of a termination letter from a prior carrier) then the Insurance company will not pay for the procedures no the grounds it was a pre-existing condition. This is verified at the time the group either come on with the insurance or when you are added to the policy.

Answer 5

The quick answer is that the insurance asks.

Certain things are a red flag in a claim system - ailments like asthma, back pain, and other injuries. When those diagnoses turn up on a claim before a "waiting period" is met (it's generally a period of time at the start of a policy predetermined by the insurance in which if a claim is filed, they reserve the right to scrutinize it for any pre-exisiting conditions and deny it if applicable.) the system kicks out the claim to be examined by a person, and usually a letter is sent to the patient asking for information - usually to the tune of "have you sought treatment for this condition within ___ period of time?" or "Was this the result of a car accident or workman's compensation?" or "Can you provide a certificate of coverage from your last plan?". Then the payment is held to the provider until this information is recieved.(So the provider also asks the patient to send back the letter) Most of the time, the pre-existing clause is waived if the patient has had insurance that ended right before the new plan began. Some plans want cold hard proof - they ask for copies of the patient's chart - and it's legal under HIPAA for them to ask for it because it falls under the Payment heading. If the plan takes the patient's word for that they never sought treatment for this condition before, and pays the claim, and then finds out later that the patient lied, the insurance will ask for the payment to be refunded from the provider - in which case, the provider can bill the patient - and sometimes, the insurance files fraud charges against the patient, since the patient *did* defraud the insurance by lying.

Answer 6

There are a lot of long answers here and I didn't take time to read them, but the short answer is: When you go to the doctor the first thing he asks is " How long have you been having this problem?" then he documents it in his file. When you file a claim, the first question on the claim is "When did symptoms first appear?" Then the insurance company request a copy of your medical file and the date the doctor put in your file should be after you purchased the insurance or it is a pre-existing condition.

Answer 7

your medical professional has to reveal all records the insurance company may request. Yea! private. I had a problem and was diagnosed with gall bladder issue, the doctor told me to go get insurance quick! It cost me over $10,000 out of pocket and would have been more if the surgeon hadn't given me a 50% discount because I didn't have insurance. No one would insure me because that doctor put a note in the record that I had a gall bladder problem. He didn't do any tests, he just made a friggin note and it cost me big time. Needless to say I don't go to that dr anymore.

Answer 8

When you apply for health insurance you give the company permission to check any and all records. Depending upon your answers to the application questions they may or may not check the records during application. However, if you have a claim they have the right to go back and recheck the records. If they find that you lied they will at best rescind the policy and may make you pay them back for anything that they've paid so far. At worst they'll charge you with fraud.

Answer 9

Usually, the insurance company send letters to the doctor's who send them bills. Those letters request the physicians to indicate if they've ever seen you for the 'condition', prior to the bill they're trying to get paid for. The doc says yes, or no... and certifies they do, or don't know if you've been previously treated as well. Its a huge paper trail, that involves your medical records & info provided to your doctor by you... good luck.

Answer 10

There's this bureau here in the US, called Medical Records Bureau, where charges are reported. It's private, so they're only going to release "$300 Radiological Services, $50 physician services" on the date - but if you don't declare it (When was the last time you saw a doctor? List all things you've been treated for) and a charge comes up, well, either you forgot, or you lied - and in EITHER case, the insurance company can ask you for detailed release of medical records from that provider. And if you don't comply, well, that violates the terms of your policy, and they don't have to pay (and can cancel you in some situations).