Health insurance is one of the most stressful yet essential parts of life. There are premiums, out-of-pocket maxes, deductibles, and a handful of other regulations surrounding your policy. All of these numbers flying around can be excruciatingly complex and tedious. It is not exactly what you want to be dealing with especially when you or a loved one is going through a medical situation.
One of the most frustrating things regarding health insurance can be fighting a denied claim. Health insurance companies would prefer not to play your claim if they can. It is money out of their pockets. However, if you don’t fight a denied claim, it is money out of your pocket.
In the endless battle over a denied claim, there are some tips that can help you out. Following these tips can potentially help you get your claim paid, but in the end it will be determined by the insurance company.
Know Why the Claim Was Denied
The first tip to fighting a denied claim, is understanding why it was denied in the first place. It is impossible to fight a denied claim if you do not have all of the facts on hand. The document you want to use to understand this is called an “Explanation of Benefits” or an “EOB”.
This form uses codes to explain why your insurance company has denied your claim. It is typically sent over when your claim is approved or denied. The document will also have a key that helps to explain these codes.
If the code does not seem right or is still ambiguous, call your insurance company. They are required to explain this information to you to the point where you can understand.
Attention to Details
Paying attention to all of the details might be one of the harder and more tedious things you do when fighting your claim. However it is also one of the most important.
First you want to check for any small errors. There have been many cases where claims were denied simply because of a data-entry error. This can be things like misspelled names, wrong insurance ID numbers, or wrong service dates.
Thoroughly go through all of the documentation sent to you by your insurance company and look for errors. If you happen to find an error, bring it to the attention of your insurance company and have them fix it before anything else. Additionally, if an error was made by your medical provider, contact them and have them resubmit the claim.
The next area of detail to focus on is the paper trail. Start putting together all of your medical documentation that can prove the services you received were a medical necessity. This can include documents such as referrals from physicians, prescriptions, and any relevant medical history. Having this proof can help to substantiate your claim.
With all of these minute details flying around it is easy to get disorganized quickly. However, you need to remain as organized as possible. Insurance companies have processes in place to keep things organized on their end, often times these are automated so they don’t have to think twice about it.
Make sure you keep all of your paperwork in one area and take notes during all phone calls. Get names of the insurance company employees you talk to along with the job title. Record dates and next steps from every call. You also want to ask for “call reference numbers” and “document image numbers”. This will help your process move along easily as you will have all of the records documented as you speak to different insurance employees.
Stick to a Strict Timeline
When it comes to your claim, time is of the essence. It is in your best interest to be prompt with all follow-ups to ensure that your claim is completed in a timely manner. You are fighting to get back a large chunk of money or to prevent owing a large chunk of money. Keep that in mind as motivation during the entire process.
Keep track of when you contacted someone and when they said the next step of the process is. If they are supposed to follow up with you in two business days, note that date. If need be call them back if they haven’t reached out to you within that timeframe. Additionally, if documents are being processed, you should find out how long the processing takes. Follow-up with the insurance company if you haven’t heard back after the processing period.
Be Firm Yet Courteous
It was probably a lie earlier to state that attention to detail was the hardest part of fighting a denied claim. Remaining calm and collective when speaking with insurance reps is probably harder. It is an emotional process that will come with a lot of pushback.
However, it is important to remember that the people you are talking to are just doing their jobs. Often times the first level of employees you speak to can’t do a whole lot in terms of fixing your claim. They are just the messengers. The goal is to move up the ladder and speak to the people who can actually help pass your claim.
Expedite the Process
If your claim is denied a second time, you can actually bring it to your state for an external review. While not all states have adopted this new process yet, it is worth checking for. If your state has not implemented this process, you can file an appeal through the Department of Health and Human Services.
Additionally, you can file an expedited appeal if the timeline puts your life in jeopardy. In urgent situations you can file both internal and external appeals at the same time. A doctor can also do this for you if you are physically unable to do it yourself.
Andrew Fujii is a marketing professional with expertise in digital/web and content marketing. He is also a copywriter for multiple agencies producing copy for blogs, articles, websites, product packaging, mobile apps, and more.
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