Health insurance policies are rejected for a variety of reasons. What do you do if you think the insurance company should have paid a claim but declined?
After running a medical billing service for twelve years, we have seen many claims rejections. The main key to getting a claim paid when it is wrongly rejected 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 issue is resolved, the more likely the decision will be reversed and the claim paid.
1. Look closely at the denial. Look for a denial code that can be numbers or letters or a combination. Now look for the explanation of the rejection codes, which can sometimes be found at the bottom of the transfer. It may not make sense to you, but it doesn’t matter. At this point, you just want to know their reason for declining the bill.
2. Once you determine the insurance company’s reason for denying a claim, you’ll have a better idea of what to do. If the reason makes absolutely no sense, call the insurance company. The rejection form usually has a telephone number. Calmly explain the situation to the customer service representative. These reps deal with calls like this all day long, so it’s much better to treat them with respect. Remember, if there’s been a mistake, it’s not this person who made the mistake; 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 that you do understand. It is very common for an insurance company to reject a claim incorrectly or because there was insufficient information on the claim form. If they falsely rejected the claim, the representative can often resolve the issue while you are on the phone.
4. If you understand the reason but disagree, call the insurance company. Explain why you disagree with the representative and ask what it takes to get this claim paid.
5. If the claim was rejected for a remedyable reason, ask the representative exactly what you need to do to rectify the situation. If you are the patient or call the patient, this may include calling your doctor’s office and explaining to the billing manager what you discovered and asking them to continue.
6. The representative can tell you that the claim was properly rejected. That doesn’t necessarily mean they don’t pay. The claim may have been rejected for timely filing. If the billing agency resubmits the claim with proof of timely submission, the decision may be reversed. (Incidentally, if the claim is rejected due to timely filing, the patient cannot legally be billed.) The claim may have been rejected due to an incorrect ID number. In this case, the ID number will be corrected and the claim will be resubmitted.
7. If a phone call doesn’t resolve your issue, you may need to file a written appeal with the insurance company. Ask the representative where to send your written objection. Fully explain your situation and the reasons why you believe this claim should have been paid. Keep copies of all correspondence and notes of all telephone conversations. Write down who you talked to, when that was, and what they told you.
Whether you’re a person trying to get your medical bill paid or you’re coming from a doctor’s office, make sure you keep good records of everyone you talk to or write to about the issue. This could be the key to getting your claim paid. If you are an individual, make sure that the doctor’s office helps you with your problem. Often they know who to talk to or how to approach the problem.
Copyright 2006 Alice Scott