the claim denial process |
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Research and Appeal a Claim Denial |
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Email: info@healthsymphony.com |
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the claim denial process |
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Research and Appeal a Claim Denial |
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Email: info@healthsymphony.com |
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Research and Appeal a Claim Denial There are things you could do to reduce the chances of your claim being denied by your health plan. Here are some of them: If you have a health plan, there will eventually be a time when you will call your health insurance company because 1) they denied a claim, 2) denied an authorization, 3) denied due to lack of medical necessity, 4) provided incorrect information or 5) performed some other action that caused you to be concerned or frustrated. When this happens, what will you do? You have choices. You could 1) save time and potentially lose money by accepting your health plan’s decision, or 2) invest a little time and save money if you found your health plan to be wrong. We hope you choose option 2. Why? Because as a consumer of a product shouldn’t you receive what you pay for? Shouldn’t health plans be held accountable for their actions or mistakes? Even after you spend time investigating a problem and find that your health plan’s decision was correct, you would have benefited from this exercise because you learned how the appeals process works if a problem arises a second time (and yes, there will be a second time). Research includes the following:
1. Investigate the cause of the denial by reading your policy booklet. Many people have never read their policy booklet or know where their policy booklet is located. The policy booklet is important because it explains what is covered and not covered by your plan. If you question a decision made by your health plan, refer to your policy booklet and verify its accuracy. If the information varies call your health plan for clarification. When appealing, submit a letter of appeal with wording from the policy booklet to make your case. Refer to your policy booklet for copay, deductible and co-insurance amounts, medical services that require authorizations, medical services that are non-covered and non-payable, phone numbers for customer service and the address of where to submit appeals. Health Plans only pay claims that are considered under their phrase "medical necessity". Make sure that your services fit this definition. 2. Document all conversations and review all of your paperwork. Document everything that is related to your problem, from discussions with your medical provider to conversations with the health plan. Document the date, time, person’s name and title and briefly state what was said in your conversation. If you find later that you were given incorrect information, refer back to your notes and specifically state in your letter of appeal the circumstances under which the information was given and by whom. If an employee of the health plan indicates that they will call you back at a certain date and time, document this. If they fail to deliver, contact a supervisor and complain that the health plan has not followed through on their promises. 3. Be Persistent. But
always be friendly in all of your conversations.
Your health plan may have unknowingly made an error and you
should initially allow them time to notice the error of their ways and
quickly resolve the situation. Clearly
and concisely state your argument either by phone, or preferably in
writing, to the health plan. Indicate
what the problem is, your evidence of where a mistake was made and your
anticipated resolution. 4. Mistakes do happen. The accuracy of claims processing of health plans varies considerably. Some accept only a 3% error percentage, while others amazingly accept a 20% error percentage. Though many claims are processed automatically, there are still a large number processed manually and susceptible to human error. Many times, a quick phone call to the health plan advising them of the error will allow them to reprocess the claim and correct the initial mistake. 5. If at first you don’t succeed, you must definitely keep trying. As long as you continue sending additional documentation and evidence, your health plan must continue to respond to you. If your health plan does not respond or avoids you, keep moving up the “chain of command”. Find the regional director or manager, Vice President, President, even the CEO to hear your case. All you need is someone, just one person with authority to say “YES” to help you in your situation. Nurses may be more compassionate than a Customer Service Representative, Medical Directors are harder to reach and more difficult to influence in their decision. Health Symphony Copyright © 2010. All rights reserved. Health Symphony provides information as a general resource and does not guarantee any results, expressed or implied, obtained from its use. |
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