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. For more information please refer to the Patient Better User guide section 3.2 “Billing, Coding, Healthcare Professionals and Payer Management”
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.