Insurance companies have been notorious for their unremitting ability to deny claims to those who need them most. We often hear about denials because the provider deems the situation not related to medical reasons but many times there can just be a simple administrative error that is keeping your claim from being accepted. If the denial isn’t an administrative error, healthcare reforms now make it easier for you to appeal and find out why your provider made their decision. If your attempts to appeal are unsuccessful you might need an attorney. First, here is what you do before you decide to hire a lawyer.
Stay Positive and Check Bill Coding
The good news about appealing your insurance provider’s decision is that there is a 50/50 chance your appeal will go through. Try to establish a positive attitude to work with the insurance providers. They are providing what you need. Although they might be making it difficult, work with them not against them.
First, grab your customer service number and find out why your claim was denied
It may be a simple administrative error or they could have deemed it medically unnecessary, but finding out why your claim was denied is important for writing your appeal. You don’t want to be sailing through the fog. Take the names of all the people you talk with and ask them to put in the record that you are working to resolve the issue.
The person you will be talking to on the phone is most likely a bottom level employee trying to do his/her job as best as possible and getting answers from a computer screen. If answers are unclear, ask to speak with a supervisor. Remember to always take their names.
Next, you’ll find out if it was an administrative error or a policy problem
If it’s an administrative error there are a few things you can do:
find out what type of error from your provider (often times there is a CPT or ICD-9 code that isn’t matching up with the information on your claim)
call your doctor’s billing services and ask them to make sure your codes are correct and tell them what you found out from the insurance company
If there is not administrative issue, let the hospital know you are working to resolve the issue. This should keep them from sending your bill to a collection agency.
If Coding Wasn’t the Issue, What Now?
Here’s where you’ll probably start grinding your teeth a bit but stay calm and keep working. This means your insurance company probably said that your claim was not medically necessary. You’ll need to go over your policy and find out why. You can find your policy on your providers website.
go over your policy and find the section that covers your case
print out this information and bring it to your doctor
find out if your doctor work your appeal and claim to fit your policy
Now It’s Time to Appeal
Click here for a step by step guide to the appeals process. If after you follow this process you still cannot get clearance from your insurance provider, it’s time to hire a lawyer and get the issue resolved.
Attorneys are well acquainted with this process and these issues. If you’d like some professional advice and help, attorneys can be the fastest way to getting through to insurance companies.
Jeremy Smith is a writer on behalf of McMinn’s Law firm in Austin, Tx. McMinn’s Law Firm is a personal injury and criminal law office that focuses on getting their clients back on track to their normal routine.