Health Insurance Claim Denied? Now What?

We pay a lot for our health insurance, too much if you ask me. So when we end up sick or injured and actually have to use it, nothing’s more frustrating than seeing a denial come through the mail.  Am I right?

I read in a 2017 study by HFMA (Healthcare Financial Management Association) that $262 billion in medical (read hospital) claims were initially denied in 2016. Another study by (Government Account Office) GAO, found the rate of denials varied significantly across insurance providers—from 6 to a whopping 40 percent.

The silver lining? The HFMA study also reported that 63 percent of the claims initially denied were eventually paid.  My family members and I have been the recipient of many, many medical insurance claim denials. Luckily, we’ve been able to get most of them paid. And if you follow some of these tips you should be able to get some of yours paid too.

First and foremost: Read your policy. A lot of problems (read denials) can be avoided when you understand what’s covered and what’s not.

  • Sometimes you think a procedure will be covered, but find in the fine print it is excluded. Finding this out before the procedure, especially if it’s an elective surgery, could save you from a big financial nightmare.
  • Is there a network that you must stay within? Using an out-of-network provider or facility can result in a denial or a reduction in benefit at the very least. Just because the doctor is in the network doesn’t mean the facility he is using for your procedure is. Always check ahead of time.
  • Does your plan require a referral or pre-authorization? Diagnostic tests like MRIs and CT scans often require pre-authorization from you insurance company.  Be your own advocate: ask the doctor ordering the test if they are going to be taking care of the pre-auth or obtaining the referral on your behalf. Don’t assume they are going to or you might end up being responsible for the bill.

Did they send the bill to the wrong insurance company?  Did your insurance change since the last time you saw this doctor?  Make sure the bill went to the correct company.  Sometimes families have coverage from two different policies.  If that’s the case then coordination of benefits (COB) could be the problem.  Depending on the circumstances, errors can occur when determining which insurance is primary vs secondary.

Transcription errors are often the culprit. Make sure names are spelled correctly and all important data like dates of birth are correct.  Typos happen more often than you think. Those claim can easily be fixed and resubmitted for payment.

The reasons for some denials aren’t as easy to identify or rectify as others. Don’t hesitate to call your insurance company (the customer service number is on the back of your insurance card or listed on your denial letter or EOB) or your medical provider if you don’t understand the reason for the denial listed on your Explanation of Benefits. Sometimes there are diagnosis or procedure coding issues, insufficient medical necessity or timely filing issues.

The two most important things to do when inquiring about a denial is to keep calm (emotions can run high during these circumstances!) and take lots of notes. Always ask for the name and title of the person you are talking to and jot down the time and date of the phone call. Before hanging up ask if there is a reference number associated with the conversation and be sure to write that down as well. There was a time when my son was having a procedure and I called both the insurance company and the surgery center prior to the procedure to verify it was in-network since I couldn’t find it listed.  Afterwards, insurance denied the claim saying the facility was out-of-network. It turned out the surgery center did not become an in-network facility until one week after his procedure.  Since I was able to provide the name of the person I spoke with, date and time of the call, along with the reference number provided during the conversation the insurance company paid the claim at the in-network rate.

If you don’t understand the reason for the denial ask questions until you do. Then if you still think the claim should be paid gather the necessary evidence you might need to get the claim paid: including referrals, prescriptions, or other relevant information. Also speak with your provider.  They want the claim paid as badly as you do.  See if there is anything you can provide to help with the appeal process.

Remember, appealing a denied claim takes time.  It’s important if you are working it out on your own to let the provider know what’s going on.  If you call them and tell them you are working with your insurance company trying to get it paid, they will oftentimes put the account on a hold, meaning they will not send it off to a collection agency.  These holds do not last forever so continual communication is a must if you want your account to stay in good standing.

The important thing to remember is just because a claim is denied doesn’t me you can’t get it paid and the three most important things you can do to move forward is communicate, communicate, communicate.

A. Alliance Collection Agency, Inc. is a full service, licensed accounts receivable management and debt collection agency providing highly effective, customized one on one management and recovery solutions for our business partners.  Founded in northern Illinois in 2005, we have been proudly improving the bottom-line on behalf of our business partners in and around Chicagoland for over 13 years.

The Sonic Boomers: Facing Tough Choices When Enough is Enough

Have you heard a ‘sonic boom’?  I have, many times when I was a kid.  I remember the windows of our house rattling, dogs barking and that deep ‘BOOM’ sounding like a bomb dropped right next door.

This memory should immediately identify me as part of the tail end of that great generation known as the ‘boomers.’  With that has come the realization that there are many significant decisions coming at me at supersonic speed. At least that is the way it feels.  Actually I guess you would call me a ‘tweener’—that is, too young yet to collect Social Security, yet close enough to need to be prepared to make intelligent decisions on a number of important lifestyle and financial choices when the time does come.

Before I go any further:   I am not a financial advisor (heck, I don’t even play one on TV!), am making no recommendations and this is not intended to provide any guidance whatsoever.  What I did want to share was a perspective on how individual these choices are and how much our heart, head–and bodies–play in making them.

With that disclaimer, I think it is fair to say that the general consensus of advisors I have read suggest taking Social Security benefits as late as possible, or at all events as close to full retirement age as practical.  The monthly benefits we receive increase nicely the longer we wait.  Yet there is an argument that goes in the opposite direction. That is, for many of us beginning to collect at the earliest possible moment, at age 62, is really the right thing to do.

This somewhat contrarian opinion came up in an article “Extending retirement age falls heavily on sore backs.” by Brad Allen, writing in the Minneapolis StarTribune.

Allen’s article initially focuses on the fact that for some of us taking benefits as early as possible is really not a choice.  Many of us have had hard, physically demanding jobs that preclude us from working longer due to injury or extensive wear and tear.  Putting up with more job related stress and strain can not only impact our quality of life, it can also be dangerous.  Yet I thought that most Americans waited until at least until full retirement age to ‘retire’.

Not so, apparently.  According to Allen: “Even though the proportion of older workers staying in the workforce past retirement age is increasing, according to government statistics, 58 percent of men and 65 percent of women applying for Social Security benefits in 2014 did so before reaching full retirement age of 66…So extending the retirement age even beyond its current limits is pushing against the overwhelming practice and expectations of the majority of older workers.”

He goes on to quote Phyllis Moen, a sociology professor at the University of Minnesota, who has studied the issue in more detail.  Her findings were that “…it’s not just the physical wear and tear from manual labor that causes people to retire early. Escaping the emotional toll of stressful work situations, providing care for an aging relative and being caught in corporate downsizings all force people to retire earlier than they otherwise might…”

Realistically, Moen contends, “…most workers are faced with only two options, full-time employment or full-time retirement…”  Allen says Moen “…advocates increased employer flexibility and policy options such as greater availability of phased retirement and prorated benefits for part-time or seasonal employment. Such moves, Moen argues, would make it easier for older workers to embark on an “encore career.”

Truly, I think that our definition of ‘retirement’ in general is changing as is the image of a ‘senior’ given improvements in health care and longer life expectancy.  These decisions are not easy, however, and they can also be complicated. Allen brings up many good points, and are worthy of consideration as we ‘rocket’ toward that point in our lives when we simply ‘do something different’ than retire in the classic sense of the word.  Knowing, though, that there is a reasonable alternative to stretching our work lives beyond reason is helpful, especially when the alternative could be very harmful.

A. Alliance Collection Agency, Inc. is a full service, licensed accounts receivable management and debt collection agency providing highly effective, customized one on one management and recovery solutions for our business partners.  Founded in northern Illinois in 2005, we have been proudly improving the bottom-line on behalf of our business partners in and around Chicagoland for over 13 years.

 

image provided by: U.S. Navy photo by Mass Communication Specialist 3rd Class Jarod Hodge

Going ‘Deep’: The Importance of Timely Response to Email

Another blog on email.  How boring you say. Well, let’s go ‘Deep’ on this one, as in Deepak Chopra.

Yes, this was a surprise to me, too, as I am most familiar with Mr. Chopra as an author and lecturer on wholeness and his suggestions for living an engaging life.

When I saw this blog “5 reasons it’s a good idea to instantly respond to emails” (read it here) I was initially engaged by the relevance of subject.  Then I saw his name as the co-author and of course the link between his name and what otherwise may be a mundane subject further grabbed my attention.

As it turns out, he and his co-author, Kabir Sehgal, are contributors to the “Leadership” forum posts on CNBC.com.   Mr. Chopra has greater name recognition but his co-author, Mr. Sehgal is a former vice president at JPMorgan Chase, a multi-Grammy Award winner as well as a U.S. Navy veteran.  They have the credibility to write on leadership, but why such a mundane subject as responding to e-mail?

Other forms of communication have supplemented, or even begun to eclipse, good old email. However, it is still the standard of communications in the business world.

However, my observation has been that how we handle our emails is all over the board.  There are opinions aplenty on the best way to handle the volume of email we receive.  Yet one thing I have noticed as well is how inconsistent we all are in simply responding to a professional and solicited email.

To be clear, spam and unsolicited email need to be handled differently.  Yet how often do you send an email to a client or colleague and it seems to just fall into something like the infamous ‘black hole?’

This is the situation Chopra and Shegal address in their blog.  How does this relate to leadership?  In my opinion it says a lot about a person, and their communications skills, when a prompt professional response is received.

As they point out, however, “When it comes to email correspondence, there seems to be two types of people: those who acknowledge that they received an email and those who don’t.”

Too true.

They go on to list five reasons that they endorse the first group and encourage prompt response.

  1. It’s courteous: Personal and professional courtesy is always welcome. “By sending a quick acknowledgement email, you are being polite, well-mannered, and respectful.”

 

  1. You will be seen as reliable: Establishing a trusting relationship is invaluable. “When you send email acknowledgments to those who contact you, you are also letting them know that you are responsive, prompt, and even trustworthy. Those who send you messages will know you’re a reliable person. You are giving the impression that you mean business and appreciate speed in your correspondence.”

 

  1. It forces you to act: I find it too easy to let an email slide down the list in my inbox.  I will get to it later. “Don’t wait around for your inbox to overflow. As soon as you get something that requires a response, shoot the sender a quick note. When you respond to someone, it creates a sense of personal accountability and shows that you’re going to take care of whatever you said that you would.”

 

  1. It buys you time: We are an impatient world.  However, “Your email acknowledgements don’t need to be long. You can simply say ‘OK’ or ‘Understood.’ By using these staccato statements, you are buying yourself time for contemplation and deliberation. Instead of someone waiting for your long reply, they will relax and cut you some slack that whatever they are requesting will get done.”

 

  1. It helps you achieve inbox zero: A great goal by any measure.  “When you reply quickly, you can move onto the next message. If you’re moving with a brisk tempo, you may be able to achieve “inbox zero” — that magical moment when your email inbox has zero messages that need a response. For those of you who are compulsive about communication, there is no greater accomplishment when it comes to email productivity.”

 

Alliance Collection Agency, Inc. is a full service, licensed accounts receivable management and debt collection agency providing highly effective, customized one on one management and recovery solutions for our business partners.  Founded in northern Illinois in 2005, we have been proudly improving the bottom-line on behalf of our business partners in and around Chicagoland for over 13 years.

image provided by: “Email” by Aaron Escobar is licensed under CC BY 2.0