Do Your Homework to Minimize Denied Health Claims

A patient balance was turned over because of continued non-payment. The patient disputed she owed the balance. The provider resubmitted the bill to the insurance and still received a denial. The following particulars of the patient’s benefit plan led to the denial:

  • She needed a preauthorization prior to the service based on the codes/modifiers submitted.
  • The service provided was classified under non-emergency care based on the chart documentation which led to a preauthorization requirement.
  • The provider was not contracted with the insurance company, meaning they did not have to accept their allowable of the charge as payment in full and could bill the patient for the entire non-covered balance of over $ 1,500.00.

As you can imagine, the patient was extremely upset. She stated it was an emergency and she experienced a lot of pain. Had she known all of the above, she would have selected an alternate service. She also felt the provider should have told her all this because it was their responsibility. She paid a lot of money to the insurance company only to receive this unfair treatment.

Six Areas for Patients to Know About

No matter what the healthcare coverage, you must take it upon yourself to know the specifics of your plan’s coverage and it is your responsibility to do so. Otherwise, you may end up with a situation like the above. If you are unsure of coverage or verbiage, ask for details. Remember, too, insurance companies also may deny charges in error. If you disagree with a health insurance decision, you have the right to appeal. Be sure to follow your insurance plans appeal process for a timely response.

Here are six areas to check prior to medical service:

  • Payment points such as co-pays, co-insurance, deductibles and percent of coverage owed after deductibles are met. There is a vast difference between amounts owed for an in network vs. out of network provider. Patients new to insurance coverage usually do not know the difference.
  • Where to go to navigate health plan information.
  • Member resources.
  • How to stay in network.
  • Out of network payments.
  • Preventative services covered.

Where can you find this information?

  • Websites: All health plans usually feature very extensive websites that are becoming increasingly more sophisticated. For example, the United Healthcare site contains lists of prices, providers by zip codes and even whether the provider is accepting new patients. Some information might be a little outdated but it’s a start.
  • Documentation: Generally, by the first of the year, healthcare plans mail out information on the changes to the coming year’s insurance. It’s easy to find deductibles, co-pays and other information via these documents.
  • Telephone: Call the number on your healthcare card. Be sure you obtain a reference (tracking) number for the call.

Because you bear a larger cost burden for your healthcare costs, digging into this information is a must to know the difference between a preventable patient balance and one you actually owe – before the bill arrives.

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