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.