Fighting Health Insurance Claim Denials
Anyone with health insurance, whether it be through a private insurance company or
a government-run health care plan, must keep detailed records regarding their policy coverage, medical services obtained, and communication with health insurance company representatives. With these insurers cutting back on offered coverage on a daily basis, claim denials are rising, making it extremely important to maintain these records.When a written policy is first received, whether it is a new policy or a renewal, it is necessary to closely read through the coverage in its entirety. Failing to take this simple step often results in obtaining services that are not covered by the policy, only later finding out that one is stuck with thousands of dollars in medical bills due to their ignorance. Health insurance companies rarely inform consumers clearly of any policy changes in the case of renewals, making it doubly imperative to completely understand any health insurance policy.
Ensure that prior approval is obtained for any identified services, as failing to do this before obtaining some services will not only end up with a claim denial, but no grounds to fight a denial on. Health insurance policies are legal documents; if a patient fails to obtain necessary prior approval for a service, the policy will hold up in court and the company will not be held liable. Do not expect a physician to be aware of any needs for prior approval, as he or she deals with countless insurance companies and cannot be expected to be an expert on all of them
Also be aware of your health insurance company's policy on in-network and out-of-network physicians, hospitals, urgent care centers, testing facilities, and specialists. Anyone with an HMO will be denied any and all coverage at an out-of-network establishment, unless the required care is not available from an in-network provider. For PPO policies, out-of-network services usually are given a small amount of coverage, but expect a hefty out-of-pocket expense in this case.
If there is difficulty in understanding any parts of a health insurance policy, all companies have a customer service line that may be called for a detailed explanation as to the particulars.
In cases in which all of the necessary precautions have been taken to prevent a claim denial, review the documentation that has been saved and have it ready when you contact the insurance company. Billing mistakes are all too common, and often may be cleared up at this point in time. Take notes on all phone conversations, including the date and time of the call, individual(s) spoken to, and any identification or confirmation numbers.
However, if a claim denial is still not cleared up, file the necessary appeals paperwork with your insurance company as directed in the policy documentation. If the initial appeal is denied, usually there are additional appeals available. In the case of continued denials, an independent review may be requested from the state insurance commissioner's office. Arbitration is another option at this point, but the most important aspect to keep in mind throughout the life of any insurance policy is to document everything.
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