At Work

When your claim is denied …

Appeal ‼️

When a health care claim is denied, the inclination is to gripe and complain, blame the insurance company and forget it. Not good

Consumers rarely appeal denied claims. In 2017, for example, the data show consumers filed appeals on about 200,000 of more than 42 million denied claims. On average, appeals resulted in a reversal of the initial denial in 14 percent of cases, though with wide variations among individual insurers, which had reversal rates ranging from 1 percent to 88 percent. Source: KFF Report

The fact is many denials are administrative in nature and can be fixed. Sometimes the claim has been coded incorrectly by the health care provider. Other times it is denied for medical necessity; a cause of much controversy and generally blamed on the insurance company – often unfairly. Sometimes, it’s just a screwup by a claim processor.

But no matter what the reason for the denial… appeal any denial.

If you are covered by your employer plan, there will be a detailed claim appeal process to follow-with time limits.

Don’t delay appealing. ‼️ Always‼️

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2 replies »

  1. .

    My career was in the related health-care industry. First call insurance customer service for them to review the claim. Claims process based on computer coding which is not always correct. Sometimes the health care provider codes the claim incorrectly In that case, your provider can file a corrected claim. If you are not happy with the customer service clerk, ask to speak with a supervisor. There are also medical department review appeals. Also it might be possible to appeal an insurance claim through the state insurance board [these get extra special handling by the insurance company.] If your insurance policy is self-directed/self-funded by your employer and only serviced by an insurance company like BC/BS, you can also appeal through your employer.

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  2. Until last year, I always thought it was BC/BS Horizon standard practice to deny a claim on the first submittal, especially if it was my wife’s claim. I can’t prove it but just maybe as part of Obamacare came the requirement for better standard coding for the billing and electronic records.

    I still do not know what I am being billed for on the 10 pages of the EOB without calling because they do not put the actual bill codes. For all I know I could be billed for using a tissue in the office or something. I am just happy that they paid the bill.

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