Challenging Rejected Health Insurance Claims

August 5, 2012 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt

According to the AHA (American Hospital Association), 87% of hospitals expect bad medical debt to continue to grow.  And it’s no wonder with situations like a very common one experienced by patients across the nation. You are seen by your healthcare provider for a service or procedure that should be covered under your insurance plan per plan benefits. However, when the Explanation of Benefits is received from the insurance carrier, charges have been denied for coverage. What happened?

Reimbursement is based on a few key areas including plan benefits and coverage period, medical necessity, correct patient information, diagnosis code, and procedure/service code (CPT), etc. An incorrect key stroke can cause your claim to be rejected. Or, an erroneous code can result in zero dollars paid. What can you do?

Begin by appealing the rejection to your doctor and the insurance company. As described above, it may have been a simple clerical error that caused charges to be dismissed. In other situations, you want to confirm that the CPT and diagnosis codes are cross referenced. What may have happened is that the CPT code did not support the diagnosis or the reverse. Codes are chosen based on the physician’s notes, documentation, and national coding guidelines. Sometimes, the CPT code may not be specific enough or it may have incorrectly described the level of care. Most insurance companies have their own unique process and timeline for appeal submissions.

If you’ve exhausted your appeal efforts and your claim remains unpaid, you may want to file a complaint with your state’s health insurance commissioner and or enlist a medical bill advocate to navigate the process for you. Whichever route you choose, be persistent, professional, and follow through.

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