These days a patient must be vigilant about his or her own
health care in terms of researching treatment, securing
pre-authorizations, and knowing what to do if their group
or private health insurance policy denies a claim. After
all, a health insurance claim denial is the last thing you
want to have to worry about in the middle of a health
crisis. A denied claim feels like a knife in the back
placed there by the very company that's supposed to be
watching your back. Luckily, some claim denials can be
easily avoided.
According to one lawyer at the Texas State Department of
Insurance, "The most common basis for a claim denial in the
health insurance industry is that the procedure,
preparation, or pharmaceutical is not covered by the
policy. So, the easiest and most important way to avoid a
claim denial is to read through the most recent and most
inclusive version of your health insurance policy and get a
picture of the kinds of things that are covered, and those
that aren't." This is a great starting point. Make sure
your policy is the most up-to-date. In the past few years
most policies have changed to put more financial burden on
patients covered.
It's also a good idea to contact your health insurance
provider and ask to talk to someone who specializes in the
area of treatment you're receiving. After all, he or she
might be the very person reviewing your claim, so feel free
to ask specific questions about what might or might not be
covered under your particular policy. For future reference,
write down his or her name and telephone number at the
beginning of the conversation. Keep detailed notes on
exactly what happens every step of the way, and retain all
related paperwork, even if you're unsure whether it's
relevant. Include in your notes:
* When the required treatment pre-authorization was
requested, and received, and from whom
* Date of the treatment
* What was discussed with the doctor, what actions were
taken, and what follow-up will be required
Unfortunately, mistakes are common in claims processing.
Consider a 2002 study by America's Health Insurance Plans,
which reported that 14 percent of claims submitted to
insurance providers are denied. The same survey found that
one out of every seven claims had to be re-submitted and
re-processed due to errors in the original claims, a costly
process for everyone involved.
Other things that you might consider include:
* Research your state's laws regarding what should be
covered in a claim, and what the law considers "arbitrary."
This would influence an insurance company's definition of
"medical necessity" and billable needs.
* Make sure your insurance provider and doctor's office
have been in contact with each other, and that all the
necessary paperwork has been forwarded from one to the
other.
* If your coverage is fully or partially paid by your
company, make sure you keep your human resources department
fully informed of the situation so that they can help with
any paperwork that might come up that you can't manage.
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Ryan Patterson is president of US Insurance Online, based
in Austin, TX. He graduated in 2000 from the University of
Texas with a combined business and computer science degree,
and started US Insurance Online in May of 2005 with fellow
entrepreneur Jim Waltrip. Visit
http://www.USInsuranceOnline.com for help shopping for
insurance and for free insurance quotes.
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