Under the Microscope: Health Insurance Applications

As a child of the '80s, I remember a line from a song that goes something like this: "It always feels like, somebody's wa-tching me-e-e. I've got no privacy." Well, most Americans apparently felt the same way, so in 2004, the second provision of HIPAA went into effect that protected most Americans' right to privacy of their medical information. I say "most," because in certain circumstances, you voluntarily waive your right to keep your medical information private from specific individuals and/or companies. One of those instances is when you apply for health insurance. In this column, we'll explore the various ways an insurance company can find out about your past (and present) medical conditions.

When you apply for health insurance, the first step in the process is to fill out an application. In addition to things like your name, date of birth, address, etc., there is a (oftentimes) lengthy medical questionnaire. In my practice, people are often amazed at the detailed nature of applications. So, the first step is also the first way an insurance company can uncover information about your medical history.

Once you complete your application, it is then sent to the insurance company by mail, fax or online. Once received by the insurance company, they input the information and then they schedule someone to call you for a telephone interview. That is the second way insurance companies verify health information. During a telephone interview, they will typically go over the health portion of the application, spending time on questions that you marked yes on. Here's a tip; it is helpful during the telephone interview to have a copy of your application on hand to refer to when you have your interview. Another useful item is to not offer any additional information that is not specifically asked for unless you are sure it will help clarify something in your favor. You should have filled the application out completely (see my July 2nd column, "Looking Good On Paper") so that you put your best foot forward. It goes without saying that you should never be deceitful or dishonest, but by the same token, you want to look the best you can to the insurance company.

Once the telephone interview is done, the insurance company may or may not check something called the MIB or Medical Information Bureau. This is a database storehouse of claims filed with insurance companies. The insurance company has to be a member of the MIB to access their information. Anything in the MIB about you is generally represented by a code that refers to the procedure you had done. There isn't a lot of detailed information there, so it's important to thoroughly disclose on the application and telephone interview whether you've fully recovered, if you had any complications, etc.

If anything in the first three is unclear, or if it is a condition that warrants it, the insurance company may request an APS or Attending Physician Statement. This is usually a form your doctor fills out requesting more information. Oftentimes medical record requests are included with the APS request. Some insurance companies will pay for the records to be copied and sent directly to them or they will have the patient (you) provide them. Here is another tip; oftentimes this is the stage of the process where your application gets hung up. Doctors typically have better things to do than copy and send your medical records. It may take a phone call (or two) from you to get them on the ball.

Lastly, a PARAMED (Paramedical exam) may be requested, although more and more insurance companies have gotten away from this practice because of the expense involved. Parameds typically consist of a traveling nurse coming to your house and taking a urine specimen and (sometimes) a blood specimen through a finger prick.

All this so you can NOT be among those 48 million without health insurance. It may seem a hassle, but the piece of mind and access to care is well worth it.