Although it may feel like your health insurance claim just falls into a black hole or gets lost in a computer system once you send it to your insurance company, there are sometimes real people who review your claim. Usually, the person responsible for this task is an insurance claim specialist, sometimes also known as a claims examiner.
Unfortunately, while you might hope that the role of Los Angeles insurance claim specialists would be to assist you in getting your claim accepted, this is often not the case. Claims examiners are employed by insurance companies and often side against policyholders in the course of performing their job to their employer’s standards. If you feel that a claims specialist unfairly or illegally determined a denial for your claim, an experienced attorney may be able to help you.
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What Does an Insurance Claim Specialist Do?
The role of insurance claim specialists in Los Angeles is to review the claims of policyholders with the goal of determining whether it is covered under the claimant’s specific policy. They also evaluate how much the insurance company must legally pay on the claim and ensure that the proper claim filing procedure has been followed per company policy.
For complicated or unusual claims, an insurance claims specialist may also assist insurance adjustors. If claims need further review after the specialist has accepted or denied them, or when a decision has not yet been determined, they can be forwarded to a claim investigator for additional review.
Other Duties of an Insurance Claims Specialist
In addition to the above-mentioned duties, Los Angeles insurance claim specialists are also responsible for:
- Examining complicated or unusual claims to determine coverage
- Researching the cost of health treatments
- Authorizing claim payments
- Setting reserves on payment
- Ensuring timely disbursement of funds to clients
- Coordinating or conducting investigations on insurance claims
- Recognizing claims with possible recovery from third parties
- Consulting with attorneys, doctors, and agents regarding the status of complex claims
In the course of reviewing claims, a specialist may consult with claimants, medical professionals, and hospital or other records.
The Question of Relevant Qualifications
Claims specialists are required to follow the California Health and Safety Code when accepting or denying claims. However, according to the United States Bureau of Labor Statistics, educational, training, and licensing/certification for these specialists vary by state and by the individual employer.
As such, one inherent problem with claims specialists is that they sometimes do not have any type of medical education or experience. This can lead to claims being denied that should have been accepted. In these situations, getting help from an insurance attorney and pursuing civil action may be worthwhile.
Get Assistance with Handling Los Angeles Insurance Claim Examiners
The role of Los Angeles insurance claim specialists should be to facilitate the efficient and accurate review of insurance claims. If you believe such a specialist is potentially affecting the review, processing, or acceptance of your health insurance claim, an attorney who specializes in insurance coverage may be able to help.
Experienced legal counsel can go to bat for you in an effort to get payment for your claims. Just as the insurance claims specialist works for the insurance company and has their best interest in mind, your lawyer can work for you and your best interests. Call today to start exploring the possibilities in your case.
