Insurance Claim Denial

To most people, an insurance claim denial letter comes as a bit of a shock. You pay your insurance premiums and expect them to be there for you when you need them. Unfortunately, this doesn’t always pan out. If you’ve received an insurance claim denial letter, don’t give up. You have options moving forward, but it’s important to understand your current status. Even if you’re not in this position right now, somewhere in the neighborhood of 200 million claims are denied every year, meaning you could be soon.

The Insurance Company Must Tell You Why

This is the first thing you have to know. If your insurance claim gets denied, your insurer has to tell you why. They can’t just send you back a letter that says, “No.” Furthermore, the denial has to be in writing and must reference your policy. Some of the most common reasons policies get denied include:

  • You missed the filing limits
  • You didn’t get pre-certification or authorization
  • Your insurance information was incomplete
  • You lack medical necessity

Now, just because the insurance company cites any of these reasons doesn’t mean they aren’t up for debate. That’s why you need to stay calm, focused and organized at the moment. If you have the reason your policy got rejected, you have the means to take a step toward getting it through. Fortunately, a lot of times, it will be something as simple as just having to fill out the form correctly or get approval from a doctor.

You Have Resources

Believe it or not, you have a number of very powerful resources at your disposal when fighting back against an insurance claim denial. Obviously, if you’re told that you didn’t get proper authorization or don’t have a medical need, you should go speak to you doctor and bring them on as an ally. They will most likely be happy to help.

Otherwise, know that many hospitals employ some type of social worker who is there to help patients just like you. They make sense of insurance forms and jargon and can play intermediary when you’re having trouble securing your coverage.

These social workers are great assets because they work for the hospital. As such, they have a very real interest in helping you see every cent you’re owed from your policy. They know that it will all be going to the hospital.

When in Doubt, Reapply

It may not sound like the most sophisticated advice, but you’d be surprised how helpful it can be to simply reapply over and over. Here’s why: insurance companies use software to help make sense of the countless claims they get every year. Did you think people were going through them by hand?

To go through all of these claims successfully, the software uses a combination of algorithms. Essentially, the program’s job is to deny as many as possible before people ever have to look them over (this is why that software is often called “denial engines”).

In any case, the more you apply, the higher your chances are of getting approved. Assuming you don’t find anything wrong with your claim and the denial didn’t provide you with any help, sending an application in over and over gives you better odds at dodging the software intended to keep you out.

Always File Electronically

Even if you’re not particularly tech-savvy, file everything electronically. Keep records too. The last thing you want is to be in the home-stretch of your approval process only to get caught up because you’re missing a form or don’t have proof you filed something you know you did.

Just because your claim got denied doesn’t mean you’re out of luck. Follow the above advice to get the money you need during this important time.

Source:

http://www.forbes.com/sites/stephenbrozak/2013/10/26/the-5-things-you-should-know-when-your-healthcare-claim-is-denied/