Denials: Denials are one of the most common problems in medical billing, and the one likely to give you the most heartburn. Typically, your insurance company requires your provider to seek authorization for medical care or to follow certain billing procedures when submitting an insurance claim to the health insurance company. If the provider doesn't follow the right procedure it could result in a denial, which simply means that the insurance company is refusing to pay for the service provided. When a denial occurs, the bill often falls on the patient. If the denial is clearly the fault of the provider (for example if they didn't comply with the insurance company's rules), the provider should resubmit the claim and try to correct the original error. Usually, your provider will be able to overturn this type of denial. However, not all denials are the fault of the provider, as some can be the fault of the patient or simply unable to be approved. Whether or not your provider admits that the denial is their fault, you should actively involve yourself in managing the process between your provider and your health insurance company to make sure that the denial is overturned. Managing the process yourself can reduce the amount of time it takes to overturn a denial and also reduce the chance that you will have to cover costs that should have been paid by insurance. You will know that a denial has been issued when you receive an Explanation of Benefits (EOB) from your insurer. In the EOB, if a denial has occurred, you will see that the insurer has denied reimbursement to your provider for one reason or another. The reason is likely to be written in fine print somewhere at the bottom of the statement. The most common denials are: | 1 | Medical necessity: Medical necessity is a very common type of denial. The health plan is essentially saying that the physician or medical provider that treated you did so without a justifiable medical reason (the procedure was unnecessary). Your physician should know best if the procedure was necessary or unnecessary. If your physician has properly documented his or her treatment of you in the medical chart showing why the procedure was necessary, you should use this information to appeal the denial. | | | | | 2 | Timely filing denials: One of the most common health insurance denials is for claims that are submitted late by the provider or yourself. These can be appealed and won. Some of the claims may be denied in error and you would need proof of the original claim submission to appeal. Assuming you or your provider submitted your insurance information on time, you should not be at fault for missing the timely filing deadline. | | | | | 3 | Others: There are many other reasons an insurance claim might be denied. When you receive an Explanation of Benefits (EOB) from your insurance company that has a denial, you will need to read through the document to identify the specific denial. The issues can complicated, but the important thing is that your provider seeks appropriate reimbursement from your insurance company for the services they provided to you. You may want to contact your insurer, your provider or both to help manage and resolve the issue. | | | |
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