Avoiding Health Insurance Claims Denials on Group or Private Health Insurance Policies, Part 1

These days a patient must be vigilant about his or her own health care in terms of researching treatment, securing pre-authorizations, and knowing what to do if their group or private health insurance policy denies a claim. After all, a health insurance claim denial is the last thing you want to have to worry about in the middle of a health crisis. A denied claim feels like a knife in the back placed there by the very company that’s supposed to be watching your back. Luckily, some claim denials can be easily avoided.

According to one lawyer at the Texas State Department of Insurance, “The most common basis for a claim denial in the health insurance industry is that the procedure, preparation, or pharmaceutical is not covered by the policy. So, the easiest and most important way to avoid a claim denial is to read through the most recent and most inclusive version of your health insurance policy and get a picture of the kinds of things that are covered, and those that aren’t.” This is a great starting point. Make sure your policy is the most up-to-date. In the past few years most policies have changed to put more financial burden on patients covered.

It’s also a good idea to contact your health insurance provider and ask to talk to someone who specializes in the area of treatment you’re receiving. After all, he or she might be the very person reviewing your claim, so feel free to ask specific questions about what might or might not be covered under your particular policy. For future reference, write down his or her name and telephone number at the beginning of the conversation. Keep detailed notes on exactly what happens every step of the way, and retain all related paperwork, even if you’re unsure whether it’s relevant. Include in your notes:

* When the required treatment pre-authorization was requested, and received, and from whom
* Date of the treatment
* What was discussed with the doctor, what actions were taken, and what follow-up will be required

Unfortunately, mistakes are common in claims processing. Consider a 2002 study by America’s Health Insurance Plans, which reported that 14 percent of claims submitted to insurance providers are denied. The same survey found that one out of every seven claims had to be re-submitted and re-processed due to errors in the original claims, a costly process for everyone involved.

Other things that you might consider include:

* Research your state’s laws regarding what should be covered in a claim, and what the law considers “arbitrary.” This would influence an insurance company’s definition of “medical necessity” and billable needs.

* Make sure your insurance provider and doctor’s office have been in contact with each other, and that all the necessary paperwork has been forwarded from one to the other.

* If your coverage is fully or partially paid by your company, make sure you keep your human resources department fully informed of the situation so that they can help with any paperwork that might come up that you can’t manage.

Leave a Reply