Medical Insurance Claim Denials – 7 Steps to Get Them Paid (By Luthando)

Medical insurance claims are denied for all sorts of reasons. What do you do if you feel the insurance company should have paid on a claim but has denied it?

Having run a medical billing service for twelve years, we’ve see a lot of denials on claims. The biggest key to getting a claim paid when it is denied incorrectly is to act on it immediately. Sometimes in a busy medical office, there is a tendency to put a denial in a pile or drawer or take care of it later, but this is a mistake. The sooner the problem is dealt with, the more likely you are to get the decision reversed and the claim paid.

Here’s how:

1. Look the denial over carefully. Look for a denial code that may be numbers or letters or a combination. Now search for the explanation of the denial codes, sometimes found at the bottom of the remittance. It may not make sense to you, but that does not matter. Right now you just want to know their reason for denying the bill.

2. Once you determine the insurance company’s reason for denying a claim, you have a better idea of what to do. If the reason makes absolutely no sense, call the insurance company. There is usually a phone number on the denial form. Calmly explain the situation to the customer service representative. These representatives have to deal with calls like this all day, so it is much better to treat them respectfully. Remember, if a mistake was made, it wasn’t this person who made it; they are going to correct it for you. Be nice.

3. If you don’t understand the reason at all, call the insurance company and ask for an explanation you do understand. It is very common for an insurance company to deny a claim incorrectly or because there was not enough information on the claim form. If they have denied the claim incorrectly, many times the representative can fix the problem while you are on the phone.

4. If you do understand the reason, but disagree, call the insurance company. Explain why you disagree to the representative and ask what it will take to get this claim paid.

5. If the claim has been denied for a reason which can be remedied, ask the representative exactly what you must do to correct the situation. If you are the patient or calling for the patient, this may involve calling your doctor’s office and explaining to the billing manager what you have found out and asking them to follow through.

6. The representative may tell you that the claim has been denied correctly. That does not necessarily mean that they will not pay. The claim may have been denied for timely filing. If the billing office resubmits the claim with proof of timely filing, the decision may be reversed. (Incidentally, if the claim is denied for timely filing, the patient cannot legally be billed.) The claim may have been denied for incorrect ID#. In this case, the ID# is corrected and the claim is resubmitted.

7. If you cannot get a solution to your problem with a phone call, it may be necessary to file a written appeal to the insurance company. Ask the representative where you should send your written appeal. Explain your situation entirely and the reasons you feel this claim should have been paid. Keep copies of all correspondence and notes of all telephone conversations. Write down who you spoke to, when it was, and what they told you.

Whether you are an individual trying to get your medical bill paid or you are from a doctor’s office, make sure you keep good notes of everyone you talk to or write concerning the problem. This can be the key to getting your claim paid. If you are an individual, get the doctor’s office involved in helping you with your problem. Many times they know who to speak to or how to handle the problem.

Copyright 2006 Alice Scott


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