Many of us have faced this financial obstacle. At times, these services include essential and costly treatments and procedures. You're aware that your plan covers your request, as the doctor's office got the pre-approval notification; so, what's the deal? The first thing that you need to do is position yourself as a knowledgeable healthcare advocate and don’t panic and identify why your claim was denied
First, identify why your claim was denied
- Common reasons applications are denied:
- Other insurance that you may have
- How much your doctor charges
- Whether your doctor accepts assignment
- The type of facility, where it is located
- The location: (test, procedure, or service)
- Does the office run fee-for-service or pay-for-performance
2. Know your supporters
Although they do not work on the financial aspect of your claim. Your doctor or licensed professional that performed the service in question could write your insurance company a Letter of Medical Necessity (LMN). The LMN is sent directly to your insurance company, so make sure that you ask for a copy for your records.
3. Keep documents
Organize and keep track of your medical bills, Eligibility of Benefits (EOB), a copy of your current insurance benefits, and your healthcare plan for quick reference. Keep a calendar specifically for health care and include the dates of the appointments, the services that are provided, and the time you pay your bills. Check for incorrect codes, duplicate codes, receipts, and payments. A well-kept document trail will reduce your chances for a second or third denial.
4. Process your claim like a pro
The truth of the matter is that your insurance company is not in your corner. The objective of insurance companies is to keep as much money in their organization for as long as possible. This process is called “adjudicating a claim.” Insurance companies do this by lowering the amount they pay your clinician and finding loopholes such as finding technical errors to deny your claim using auditing software also known as “claim review programs.” There are different claim review program algorithms for each insurer; therefore, the odds of approval or denial are not exact and could take years to rectify.
Apply, check, reapply, check and submit your claim again.
For more information please refer to the Patient Better User guide section 3.2 "Billing, Coding, Healthcare Professionals and Payer Management"
Saving on healthcare costs requires a little finesse. For you to be able to accomplish this is the key reason why Patient Better exists. We want to deliver you a product in which you can afford, that will help you save money and continue to receive good quality care.
First, work the Patient Better System.
Go through the videos, read the User Guide, and then organize what health documents that you already have. Don’t worry, Patient Better walks you through this process step by step. Going through this is easy and you’ll really like it if you have kids. For your kids sake and as they transition into adulthood, you’ll find that this is one less thing that you have to worry about and something that they will be able pick up where you left off.
Now that you have completed the system…
You are prepared from the beginning stage of your onset to research and communicate with any healthcare professional. By being able to properly research, you will be able to price accordingly, understand the benefits and limitations of all services, products, and time needed to take care of your diagnosis as well as track and document the entire occurrence.
The Centers of Medicare Medicaid Services and the American Medical Association have developed unique coding systems to indicate the quality of care being delivered. These codes are used to document the patient’s medical record and to track treatment of protocols and outcomes. These codes are known as the Current Procedural Terminology (CPT) and the International Classification of Diseases (ICD) codes. When these codes are reported consistently, providers may be entitled to additional payments if they meet predetermined reporting thresholds.
Created by the American Medical Association Current Procedural Terminology (CPT) is a medical code that is used by healthcare providers to report, surgical, diagnostic, and medical procedures and services to insurance companies and accredited organizations.
The CPT is what we consider the “what” the practitioner is doing. The CPT is applied to the professional executing the services. So using the example of surgery, imaging, or any medical procedure, the CPT is a designated code for whatever service the licensed professional has performed.
The International Classification of Diseases is a global medical information standard for morbidity and mortality statistics. The ICD is used in clinical care and research to define diseases as well as study disease patterns, monitor outcomes, manage health care, and helps allocate resources. The ICD is what we consider the "why" in the coding system. An example would be that the surgeon completed knee surgery, the CPT code would be attached to the service of the knee surgery. The ICD would then associated with the CPT code which indicates "why" the surgery was performed such as if the patient was injured or had arthritis in their knee. Dr. Cohen completed knee surgery on Jane Doe due to an advanced stage of arthritis in her knee.
On October 1, 2015 the WHO authorized a publication, supplying a more robust, pinpointed, developed code set to mirror the recent changes in the medical and healthcare field.
For more information please refer to the Patient Better User Guide Section 3.2 "Billing, Coding, Healthcare Professionals and Payer Management"
Regarding researching health information on the Internet, it’s ok to look. The problem for most of us is it’s difficult to discern which health information is credible and which is not. So instead of telling the doctor, people err on the side of caution to avoid feeling foolish.
In Section 3 Part 7 in your Patient Better User Guide, we discuss further ...
Be upfront to your providers about your financial philosophies; that way, they will be able to coordinate a treatment plan that can up your chances for the best odds for your compliance throughout your health occurrence.
The Insurance-Driven Patient
If you are an insurance-driven patient, you prefer to stay within the guidelines of what your insurance offers. You generally seek care providers that accept your insurance, and you will not consider treatment outside the scope of the pay schedule and want the minimum out-of-pocket expense.
The Best Practice Patient
You found the perfect doctor that accepts your insurance, which is a plus but does not influence your care decisions. You only use insurance when convenient; you like to have all the health cards on the table. Your provider’s recommendations ultimately determine what care you will receive. The office is a little far away, but he has an excellent bedside manner. You prefer to follow recommendations.
The Rogue Patient.
This is what I call the patient that wants all the options on the table, regardless of cost or insurance approval. Perhaps you have a specialist that you prefer to perform your surgery; cost and quality are everything. For example, there is a physical therapy center that your doctor is unaware of, but it’s close to work and is open the times that meet your needs; however, it does not accept your insurance- but hey, it beats asking the boss for time off from work.
The Experience-Based Patient
Will you go to great lengths just to avoid a physical? Perhaps you get overwhelmed at the ambiguity of the costs and are too confused and avoid the ever-changing healthcare scene altogether. Chances are, every time you go to a doctor, it’s the first time. Maybe you seek quality care and prefer to pay out of pocket as the confusion of ambiguous medical expenses through insurances only stand in the way of focusing on care. You want the most cost-effectiveness and convenience in every aspect.
First, understand the 4|6 Step Medical Office Visit Process. This is Patient Better’s explanation of the healthcare practices’ and the patient’s series of steps and actions needed to complete a successful medical office visit. The 4|6 SMOVP process was developed for everyday people to see the layout in which a typical patient goes through as protocol of the medical office likened to a patient’s process when visiting under the care of a clinician.