Why Do Medical Claims Get Denied? What Should You Do When They Are?

Why Do Medical Claims Get Denied? What Should You Do When They Are? Health insurance claim processing involves medical records review among other formalities. Understand why claims are denied and what to do in such cases.

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Health insurance is a great option when you have to undergo advanced medical treatments that are costly but indispensable. Typically, health insurance covers hospital expenses including pre- and post-hospitalization as well as in-patient treatments.

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procedures, domiciliary expenses and much more may be covered under health plans.

When evaluating health insurance claims, insurance companies determine the legitimacy of the claims by reviewing the medical records of the claimants with the assistance of medical review companies experienced in this regard. Sometimes, health insurance claims are rejected and there are certain reasons why this happens.

Reasons for Claim Denial •

Waiting period involved: Health plans typically include a waiting period, or the period during which some pre-specified diseases may not be covered. If a claim is filed for one of such specified illnesses before the waiting period is over, the claim will be denied.

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Pre-existing diseases: Some health insurance plans do not cover any pre-existing diseases you have while buying the policy. If you fall ill on account of these diseases and then make a claim, it will be rejected.

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Inaccurate information: There is a great likelihood of claim rejection if you provide wrong information or do not reveal all facts related to your health condition, nature of employment, or pre-existing health conditions. Other issues may be a billing error on the statement, mismatched billing codes or missing medical records.

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Health plan period: Usually, a health insurance policy is valid for a year. It will expire after a year. It is important to renew the policy at the end of the plan period so that it is active. If a claim is made on an expired health insurance policy, it will be rejected.

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Exclusions: These are conditions included in the policy under which a plan member cannot raise a claim. A claim filed against an exclusion of your policy will be rejected. Therefore, it is important to read the policy document thoroughly and clarify any doubts you may have with the insurance company.

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Experimental, investigational, cosmetic, or not medically necessary procedures: Many health plans do not cover these kinds of procedures and claims for these will be denied.

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Absence of documentation: Your claim may be denied if it is for a procedure for which a referral or pre-authorization was required but was not provided.

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Out-of-network provider: If the claim is for a procedure or treatment from a provider that is out of the insurer’s network, the claim will be rejected.

What to Do if the Claim Is Denied?

If a health insurance claim is denied, the claimant can appeal the decision and have it reviewed by a third party. The claimant can request the insurance company to reconsider its decision, and this is the first step in the appeal process. This usually involves a medical peer review or a peer-to-peer phone review between the claimant’s doctor and a doctor the insurance company appoints. The insurance company has to tell the claimant why the claim was denied. There are two ways to appeal a claim denial.

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Internal appeal: When a claim is denied or health insurance coverage cancelled, the claimant can go for an internal appeal. They can ask the insurance company to carry out a full and fair review of its decision. The insurance company is required to speed up this process if the case is an urgent one.

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External review: In this, the claimant has the right to take his/her appeal to an independent third party for review (external review). This means that the insurance company no longer gets the final say over whether to pay a claim.

The claimant must follow his or her health insurance plan’s appeal process. It is best to contact the insurer’s website of call their customer service to get detailed instructions regarding filing the appeal and completing specific forms. Find out if there is a deadline for filing an appeal.

Avoiding Claim Denial •

Know exactly what is covered by your insurance plan: Study in detail your summary of benefits or call your insurer before undergoing treatment.

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Be compliant with the rules of your health plan: For this you have to be knowledgeable regarding the types of care that would require pre-authorization and such other details.

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Understand the limits on your benefits: There may be restrictions regarding the number of home health visits the plan allows, and such other limits.

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Check whether your healthcare provider is in your plan’s network: You must be careful regarding this because based on the type of plan you have, your insurer may not pay anything for treatment received from providers that are out of network.

www.mosmedicalrecordreview.com

918-221-7791

Professional legal assistance is something claimants could consider if their claims are denied. Since most people are not experienced in dealing with insurance companies, it is best that they have an attorney to take care of the negotiations and clarifying things to the insurance company. Right from the time of filing a claim, an experienced attorney can help claimants understand the legal validity of the claim. Attorneys obtain a clear view of the medical aspects of the case with the support of medical review companies and can tell you whether the claim will be approved or not. Also, legal support is vital if the insurance company has denied your claim without conducting a proper investigation.

www.mosmedicalrecordreview.com

918-221-7791