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EDUCATING INDIVIDUALS AND FAMILIES ABOUT APPROPRIATE AND AFFORDABLE
MEDICAL / HEALTH INSURANCE OPTIONS

How to Prevent Health Insurance Claim Denials

There are things you could do to reduce the chances of your claim being denied by your health plan. Here are some of them:

Prevention Section

  1. Review your policy booklet and understand the benefits and limitations to your policy. Know what is covered and what is not covered. If you don’t understand an aspect of your health plan, contact your health plan for them to explain it thoroughly.
  2. Not only should you know your policy limitations and coverage, but when visiting a medical provider, your physician’s office should also know what these are. Have they contacted your health plan to check on benefit information prior to you receiving medical care or scheduling a surgery?
  3. Document everything. If you receive instructions from your health plan or from your medical provider, document what was told to you, who told you and when. This information is crucial if you do receive a denial and then need to appeal.

Prevention Details, Specifically:

  1. Inpatient Hospital Visit/Surgery - Review your policy booklet to determine if an authorization is required. Have you confirmed that one was done, if so, what is the authorization number and what specifically was approved by your health plan?

  2. Out of Network Prevention - If you are scheduled for a hospital stay, due to a surgical procedure, have you confirmed that all of the providers, including the facility, are contracted with your health plan? Have you checked the radiologist, pathologist, anesthesiologist, hospitalist, specialist? Each one of these entities could work at the hospital, but may have their own billing and each must be contracted with your health plan to be considered in-network.

  3. Usual and Customary Prevention - If you are aware that you will receive services from an out-of-network physician, then you should already ask what their fee will be, instead of being surprised when your health plan determines that your physician billed too much for that procedure. The result is that you will be responsible for the bill. Any opportunities to pre-negotiate a fee with your physician and to confirm the amount charged will be beneficial and reduce Usual and Customary Denials.

  4. Coverage Issues - Has there been a change in your eligibility? One of the most common health insurance denials is due to eligibility issues of the patient with their health plan. Are all of your dependents included on your plan? What about your newborn? Have you kept your plan up to date? Were there any changes during open enrollment at your work place?

  5. Delayed Claims ConsiderationBe aware of when your health plan considered your claim for a medical procedure. It may take between 45 to 90 days for a claim to be filed to your health plan from your medical provider and for your plan to consider the claim. If much more time has elapsed beyond this time period, then your claim may not have been billed, not have been received, may be pending additional information or may have been denied. Call your health plan to inquire about the claims’ status.

Final Words:

Though it may be impossible to completely prevent a claims denial, the information above could reduce the potential of one occurring. It does require that you as the consumer do some homework and take the necessary initial steps to learn more about your policy and its potential limitations. It also requires that you are working with your physician to identify potential problems when seeking medical care and continue to develop this relationship, as they would be very beneficial during the appeals process.

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