A health insurance claim denial is the first step in a battle with your insurance company to have your procedures, treatment, medication, medical devices or other health care approved and paid for, and it is a process no patient wants to go through. Even if you eventually win, the fight for coverage can be aggravating, time-consuming, and deleterious to your emotional or mental health.
While there is no way to guarantee that an insurance company will approve your claim on its initial submission, there are tips for preventing your claim from being denied that you can follow to hopefully improve your chances.
If a procedure requires pre-authorization, make sure to seek it out and ensure it is granted. If possible, contact your insurer in advance and find out whether your treatment needs pre-authorization. Also, find out if referrals are necessary in order for you to visit a specialist.
Make Sure All Information is Complete
Before submitting your claim form, make sure every field is filled in, and that the information is correct. Incorrect or missing information on a claim form, such as the wrong Social Security number, can be a major trigger for denials—many of which may be valid and not the insurer’s fault.
Know Your Insurance Plan
Some treatments are not covered in an insurance plan, so before pursuing a procedure, you should make sure you know whether or not that treatment is covered under yours. Every patient should receive a handbook from their insurance provider outlining what is and is not covered. These plan documents are often called an Evidence of Coverage. If there are questions, call the insurer to find out whether the treatment is covered prior to proceeding with it.
File on Time
The insurance company may require that a claim is filed within a certain timeframe. Know what the timeframe is and make sure the claim is filed by the deadline. In general, it is always best to file a claim as soon as possible.
Confirm That All Relevant Doctors and Facilities Are in the Plan
When going into the hospital or clinic for a procedure, find out in advance if everyone involved in your care is part of your plan, including any anesthesiologists and/or specialists. If they are not included in your plan, they are considered out-of-network and may cause you to suffer additional charges or a claim denial.
Inaccurate billing codes are another common source of denied claims. A patient may not know their specific diagnostic codes since they are very specific, but if the doctor’s office makes a coding error, the claim may be denied. If concerned, call your doctor’s office and ask a claims representative to double-check all coding.
Getting in Touch with an Insurance Denial Attorney
Receiving an insurance claim denial can be a traumatic experience—not to mention an expensive one. In order to ensure your claim has the best chance possible of being accepted, follow the aforementioned tips for preventing your claim from being denied and contact a local health insurance lawyer if you have any questions or concerns.