When a health care claim is denied, don’t walk away

I spent nearly fifty years listening to and resolving employee problems with their employee benefits, mostly with health insurance claims.  Sometimes that was not an easy task; things do go wrong after all and surprisingly (not really) more often than not the problem is not with the insurance company, but rather with the health care provider’s office with the care provided or with the employee/patient.

What to do when a claim is denied

If you believe that your claim for health benefits has not been processed correctly or wrongly denied, do something about it, say something, investigate and appeal the denial if necessary.  Your first resource is to call the insurance company or in the case of a self-insured employer plan it may be what is called a third-party administrator.  You may also have to call the health care provider to be sure the claim was filed correctly or filed at all.  Do not pay a health care provider until you are sure the claim has been submitted and any dispute is resolved.  Getting reimbursement for a payment you need not have made can be difficult.

Appeal your claim denial

If you cannot get resolution after the above steps, talk with your employer’s human resources group or your employee benefits department.  You have the right to file a formal appeal and if necessary to request an external review of your claim for benefits.   The Affordable Care Act sets new requirements for both internal and external review procedures.  Some of these requirements are not currently in effect; grandfathered plans have more time to comply. If your employer plan is a self-insured plan and has lost its grandfathering, the external appeal process is now in effect, but your employer is not required to tell you about it until January 2012 (I know, sound nuts doesn’t’ it but that’s the regulation).

Ask your employer, other plan sponsor or your insurance company for a copy of the claim appeal rules they are required to follow.

Lessons learned

Several years ago an employee who was about to lose his house as part of a lien for non-payment of medical bills called me; lousy insurance right?  Not exactly, this person never bothered to tell anyone he had insurance, never filed a claim himself and for many months simply ignored the bills he received.  We fixed the problem and saved his house although I am not sure why.

Another incident involved an article in the company newspaper asking for donations to help a fellow employee defer the cost of health care for a sick child.  Supposedly there were thousands of dollars in bills not covered by his insurance.  Knowing the type of coverage he had, I knew that his publicized situation was virtually impossible. In reality he did not have any large bills that were not paid or payable and at the time he only had a $150 deductible (long time ago, right?).  His providers never bothered to submit claims, just sent bills and the employee never bothered to give his insurance information, he just complained to fellow workers that the bills were mounting up.

I once had a claim for a child being treated for Lyme disease with IV therapy to the tune of $12,000 a month.  The insurer questioned the medical necessity and after several months denied further payment without additional justification. The employee claimed the insurance company was arbitrarily denying needed care. I instructed the employee to file an appeal and as part of that appeal I referred the case to an external independent third-party.  The report came back that there was no clinical evidence in the medical records that the child even had Lyme disease. The doctor evaluating the case made the comment that what he saw being done to this girl bordered on child abuse.

In these cases the employee never asked for help, never followed up on any aspect of his coverage until there was a crisis (and were quick to blame the insurance company rather than consider the real cause).

 

 

 

Have all the facts and give the full story

Employees would tell me about unpaid claims or denied claims and nearly always had lots of four letter words for the insurance company.  Sure there were times when the insurer made a mistake, lost a claim, incorrectly interpreted a plan provisions or even denied a claim that should have been paid, etc. but those times were rare compared with the mistakes and misinformation given out by doctors and their staffs.  Employees would be told a service was not covered when it was eligible under our plan, claims would be coded wrong and thus denied based on the coding, and employees would be balance billed when the provider had a contract not to do so.  Sometimes the claims were not submitted by the doctor, the patient billed, the bill paid and the employee criticized his lousy insurance coverage.

Be upfront and honest

When employees did call about a claim problem, they frequently left out a few details like they had not met their deductible; the claim was not for the service they stated, they had in fact, received a detailed explanation of why the claim was ineligible or the unpaid claim they were calling about with a collection agency on their back was for services from a year ago and they had simply ignored the matter. But of course, it was always the insurance company’s fault and never the doctors. This was especially true when a payment was limited to the reasonable and customary fee.

 By all means appeal a claim that has been denied and do so without delay there are time limits on such appeals, follow the steps I outlined above, but also be sure that you have all the facts and honestly relate them when you discuss your problem.

Related articles

• Appealing denied health insurance claims-know your rights for an external review (quinnscommentary.com)
• Do You Speak EOBese? (rjwh617dotcom.wordpress.com)