Appeal a Health Plan Processing Error

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Physicians and medical providers attempt to submit claims electronically to the health plan.  If this is done, it assists the health plan to automatically process claims in their system and to determine payment without manual intervention.  Though this does not eliminate errors, it speeds up the claims processing function at the health plan and payments are sent out to medical providers faster.  But, there are still a lot of claims manually processed by health plan's claims processing units which may increase the susceptibility of errors occurring.  In a survey conducted several years ago, we found that certain health plans allow only a small percentage of acceptable error in the manual processing of claims, usually less than 3%.  However, it was surprising that some larger health plans had a higher threshold of acceptable error in range of 15-20% due to the high volume of claims received and not wanting to slow down and create a backlog of unpaid claims. 

Knowing that health plans make mistakes at various percentages is a major reason why every patient should review your EOB (Explanation of Benefits) to quality check that the claim appears to have been processed correctly, with the correct physician paid, the correct copay or deductible applied and the correct amount of patient balance to be paid.

How do you combat health plan processing errors? The following are steps you should take.

1. Closely scrutinize your explanation of benefits and contact the health plan's customer service unit for them to describe any questions you may have on the processing of your claim.

2. If you have an HMO and don't receive EOBs, then you could determine if your health plan covered your medical service if you receive a bill from that physician, because normally you would not receive a bill and should only be charged for the copayment as determined by your plan.

3. If a mistake is made, attempt to contact the health plan's customer service unit and explain the error that was made.  If the health plan can easily identify the error made, they should immediately send the claim to be reprocessed and make a correction of the payment.

Sometimes, the health plan will not accept phone calls to overturn denials and a written appeal will be required.