Issue: Pre-existing Condition

Action: Pre-existing condition refers to the terms & conditions entered into between the carrier and the patient / subscriber before the beginning of the contract. The rejection will usually say that the claim is being denied due to the pre-existing condition. It would not specify what exactly the condition is. So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything. (Ex.) A) There may be a condition that for the first $5000 worth of medical expenses the patient should bear it himself and the carrier would start paying for expenses after crossing that limit. If the patient has not yet exhausted the threshold limit then the claim would be denied for the pre-existing condition. B) There may be a condition that the carrier would not be paying for the same diagnosis more than once in a year. If a same diagnosis code is used on two occasions in the same year then the carrier will deny the claim submitted for the second time stating ‘pre-existing condition’.

As soon as you receive the denial, work order can be issued to Insurance calling. Check with insurance on the preexisting condition.

If the patient has secondary coverage: Check whether we can send the entire bill to secondary along with the primary denial. Some carriers may be willing to pay for the same. If the secondary agrees, bill the secondary along with the denial obtained from the primary.

If the patient has no Secondary Coverage / Secondary refuses to pay: Flip the balance to patient.

Executive Summary
Before the Affordable Care Act, Americans with pre-existing conditions who did not receive health coverage through their employers had few affordable options to get the care they needed. In most States, insurance companies could refuse to sell them coverage, charge exorbitant premiums, or offer them coverage that excluded benefits for their health conditions. The result has been tens of thousands of Americans with serious health conditions – like cancer and heart disease – who have been unable to afford health insurance or to pay out of pocket for their own medical care.
Thanks to the Affordable Care Act, people with pre-existing conditions have new options. The health reform law contains significant benefits for people who are living with pre-existing conditions, expands access to private insurance, and gets rid of the worst insurance industry practices by putting patients first.
The law ends discrimination against people with pre-existing conditions. Insurers can no longer deny coverage to children because of a pre-existing condition and starting in 2014, refusing to cover anyone with a pre-existing condition is prohibited. Insurance companies will also not be allowed to charge higher premiums based on health status, pre-existing conditions, or for being a woman. This will allow millions of Americans and small businesses to purchase affordable coverage through a new competitive insurance marketplace and have the same choice of insurance that Members of Congress will have.
As a bridge to 2014, when these protections apply to all Americans, the law created a new program designed to help the tens of thousands of Americans who have been locked out of the insurance market due to their health conditions. The Pre-Existing Condition Insurance Plan or PCIP is a temporary high-risk health insurance program that makes health coverage available  and more affordable immediately to individuals who are uninsured and have been denied health insurance by insurance companies because of a pre-existing condition. Twenty-seven States are operating their own program, often in coordination with existing State High Risk Pools, and 23 States and the District of Columbia have opted to have a Federally-operated program. 
Our analysis of PCIP demographics and enrollment trends show the program has worked quickly to connect Americans in need of medical care with the health insurance they need. Already, PCIP is helping 50,000 people with medical conditions access the health care they need but have been unable to afford without health insurance. Americans seeking health insurance through PCIP have serious health care needs:
• Delayed or Deferred Care: To qualify for PCIP, applicants must have been uninsured for a minimum of six months prior to applying for coverage, which means that PCIP may attract individuals who have been recently diagnosed with a severe illness or condition that requires immediate care or treatment. Additionally, people who may otherwise qualify for PCIP may exclusion with respect to such plan or coverage. postpone enrolling until they have an immediate need for coverage. As a result, PCIP
enrollees use a higher volume and intensity of services than those in existing State High Risk Pools, which pre-date PCIP, and enrollees in an established Federal Employee Health Benefits (FEHB) health plan.
• Serious, Expensive Illnesses: In general, the top five diagnoses or procedures in terms of cost tend to include cancers, ischemic heart disease, degenerative bone diseases, organ failure requiring a transplant, and hemophilia. These illnesses are prevalent among PCIP enrollees:
* With cancer among the most costly conditions to treat, in 2011 the Federally administered PCIP served 628 enrollees with this diagnosis, including 333 enrollees diagnosed with breast cancer.
* Also in 2011, the Federally-administered PCIP had covered more than 1,000 enrollees with a diagnosis of either ischemic heart disease or heart failure.
• Higher Risk Populations: Older Americans are at greater risk of having health conditions and needing care. The largest segment of PCIP enrollees is age 55 and older, which is likely attributable to people who are retired or no longer working, do not have access to employer sponsored health insurance, and have not yet reached the age when they can enroll in Medicare.
The PCIP program has changed tens of thousands of lives, and in many cases, literally has saved lives. This report demonstrates the significant needs of those with pre-existing conditions and highlights the importance of programs such as PCIP.