I have experienced denied claims and they can be very frightening and frustrating. My first reaction was how is this possible when I pay for health insurance. Most of us do not really know what our health insurance covers and what are the procedures to secure payment. Hopefully, the following can help.
Health insurance companies deny healthcare bills for a variety of different reasons. Normally there is a legitimate reason for the denial. The healthcare consumer should be prepared for such an event. They occur more than you may think. Healthcare providers receive the denials from the insurance company and automatically bill the consumer. The consumer is now responsible financially for the bill. The following are common reasons bills are denied.
- Medically Unnecessary Services
The medically unnecessary denial is a denial that insurance companies use when a claim does not meet their medical criteria for payment. This can occur when your healthcare provider has improperly or did not fully document your medical service.
- Medical Service was not Pre-Authorized
Many healthcare services require the healthcare provider to obtain an authorization from the insurance company, prior to service, to obtain payment. Healthcare providers sometimes miss obtaining a pre authorization. If this occurs, the healthcare consumer can call the ordering doctor and healthcare provider to appeal the denied claim. Most insurance companies will grant a retro pre authorization which means they approve the service after the service was rendered. . If not, the healthcare provider should not bill you.
- Non-Covered Charges or Services
Some healthcare services can be excluded for payment as defined in your health insurance policy. These excluded services are generally those not frequently used by the healthcare consumer or are very expensive procedures. Before receiving or scheduling services, contact your insurance company to insure they are covered.
- Wrong Information on the Claim
Healthcare providers and insurance companies can make errors that will result in a denied claim. Examples for these types of errors are:
- Wrong Insurance Information
- Wrong Patient Information
- Transposed Information on the Claim
- Wrong Information in the Insurances Companies Computer System
Anything can go wrong. Be prepared to deal with these situations.
Insurance companies will send the healthcare consumer an Explanation Of Benefits (EOB) that will have specific codes explaining why a claim has been denied. Take the time to understand the reason for the denial. The reasons will lead you to the next steps in appealing the denials
The Healthcare Consumer Navigator Center has a step by step process as to how to appeal denied claims.