Uh Oh, Denied Claims

Once in a while, when you have a test or treatment that isn’t covered, or you get a prescription filled, your insurance company won’t pay the bill. You can still get the treatment your doctor recommended, but you will have to pay for it yourself.

Many insurance claim denials are paperwork errors.  A medical billing company may spell your name wrong,  mess up your policy number, or list a wrong date of birth.  And the insurance company is definitely going to deny your claim if the coding says that your 8 year old son is pregnant.  Duplicate bills are a common occurrence and will result in the later one being denied.

The second largest cause of denied claims is eligibility problems.  Make sure that your insurance is still in force before undergoing medical procedures.  Most insurance companies will provide some leeway for a late payment, but not for long.  You might not even know if your employer has missed a few payments or accidentally dropped you from their roles.

The third major cause is eligibility.  Health insurers may deny claims for procedures not covered in the policy or considered not medically necessary.  Cosmetic treatments like tattoo removal or plastic surgery are rarely covered.  Neither are most weight loss surgeries. If there is any doubt, call your insurance company first.

A lot of eligibility problems start in the emergency room.  ER fees are very high, and insurers want to limit their use to true emergencies.  It’s easy to see that you shouldn’t go to the ER for a simple cold, but it becomes a gray area if you’re an asthmatic and the cold has caused breathing problems.  The problem is compounded when the ER bills for a URI (upper respiratory infection) rather than a life threatening breathing problem.  This type of problem can usually be corrected with an appeal.

If your insurance company denies your claim, you have the right to appeal the decision. Before you start, become familiar with your insurance company’s appeal process. This should be discussed in your plan handbook. Also, ask your doctor for his or her opinion as he or she may be able to help you through the process.

Be sure to document your appeal thoroughly and keep copies of everything. During the appeal process, your appeal and the original denial will be reviewed. You want your appeal to be the more believable of the two.  Most insurance companies allow two levels of appeal, and most states have set appeal requirements and standards.