Each health insurance claim is unique in some ways. You are an individual and can benefit from having an experienced health insurance attorney conduct a thorough analysis of your claim. Health insurance companies have standard procedures and guidelines for how they respond to claims. Each insurance company has their own procedures, and plans have different co-pays, deductibles, and out of pocket payments. Since you do not deal with the insurance claim process on a regular basis, it is understandable that you may feel overwhelmed and completely at the mercy of the insurance company. You do have certain rights and you do not need to feel defenseless if you experience the denial of an insurance claim. 

Delayed or Denied?

It is important to note that insurance companies often drag their feet when processing claims. Most claims are delayed or have the process stalled at some point due to minor things like a medical coding error or a missing authorization requirement. It is unfortunate that obtaining proper compensation and reimbursement for the medical coverage you pay for requires you to deal with what is often an inefficient, unnecessarily complex system that seems to work against you the consumer. Many employees of health insurance companies are overworked and lack proper training. Even if your claim is not denied, a prolonged delay causes a great deal of stress by leaving you in limbo. A delay can also threaten your financial security by preventing you from receiving payment when you need it. 

How to Handle A Delayed Health Insurance Claim

A delay may be due to the health insurance claim being investigated. It could also be the result of miscommunications within the company and employees not properly processing the paperwork. Each plan type has its own guidelines, and overwhelmed employees who do not know the system are prone to make mistakes. Even though a delay is likely not your fault, try to remain calm and be courteous with all of your communications. 

  • Contact the hospital: It can take a while and several attempts to finally reach the person who is in charge of billing and can help you with checking on the status of the claim. It is another area where people are often overworked and have a lot of paperwork to handle for many different people. Be persistent and keep calling until you reach the right person who can help you. 
  • Contact your insurance company: Health insurance companies get a lot of calls from frustrated, angry policyholders. They are more likely to help you when you are polite and understanding of their situation. The representatives have guidelines they must follow and they must initially take the time to confirm your identity and collect all information about your claim before they can begin to determine why it may be delayed. If the customer services agent is rude to you or unable to help, ask to speak with their supervisor. Be prepared to spend some time on hold. Be calm and persistent. 
  • Meticulously document your efforts: Keep detailed notes of all phone calls and other communications with your insurance company. Record the date and time of the call along with whom you spoke with and a description of the conversation. Proper documentation is crucial when making a health insurance claim. If any customer service representative states they are taking some action or offers to make an adjustment of some sort to your bill, ask them to send you some confirmation in writing or by email. 

You may receive bills for services that should be covered by your health insurance. It is possible that the services are actually covered but an incorrect billing code or other typo resulted in you being charged. With the complexity of health insurance billing, you could benefit from a simple review of your claim and the paperwork by a knowledgeable health insurance attorney. Simple mistakes can be difficult to identify if you are not familiar with health insurance billing. 

Common Issues That May Result in An Insurance Claim Denial

A medical claim can be denied for a wide variety of reasons. The Department of Labor estimates that one out of seven claims made to employer health plans is denied. However, the denial often is the result of some type of error in the claim. Your odds of winning an appeal are very good when you receive help from an experienced health insurance attorney. While submitting a claim and dealing with the insurance company can be confusing, you have many resources available to help you each step of the way. Understanding why an insurer may delay payment or deny a claim can help you prevent some unnecessary delays and be empowered when you do need to appeal a denial. 

  1. Untimely filing: Timely filing deadlines vary by insurance carrier. Some companies have filing deadlines as short as 30 days while other carriers will allow up to two years. A claim may be denied over timely filing even though the claim was submitted within the deadline but not received by the insurance company. Some denials for untimely filing may occur due to simple mistakes that could easily be avoided. Being denied for untimely filing does not mean you are unable to appeal the denial or that you will not be paid. You will need some expert guidance to help you handle this type of denial. 

  2. Services are excluded or not covered: The services of some medical offices may be excluded from coverage by your policy. You are required to pay 100 percent of the costs of these services. If the service in question is not specifically listed in the exclusions portion of the insurance plan, the insurance company needs to explain why it is denied or classified as not medically necessary. It is possible that a specific service is considered not covered because it was not pre-authorized. You can contact the hospital to see if they completed a pre-authorization before providing the needed service. 

  3. Prior authorization or precertification required: If a service is labeled as non-emergency, your insurance carrier may require prior authorization. It is common for insurance policies to require pre-authorization for many types of expensive tests and screenings. It is a good idea to review your policy to see if any surgeries or inpatient admissions also require pre-authorization. If any of these services are provided to you without being approved in advance, payment will almost certainly be denied by the insurance company. There can be an exception if the services are considered a medical emergency. Some insurance providers also allow for a retro-authorization when it is requested within 24 to 72 hours.

  4. A cosmetic or experimental procedure: While it may seem an unwinnable case when an insurance claim is denied because it was for an experimental or cosmetic procedure, there are some instances when it can legitimately be appealed. In this situation, the providing doctor's opinion of the surgery or procedure being necessary can make a difference. A reconstructive procedure is covered by most health insurance policies. If a surgery is categorized as elective, it will likely not be covered by health insurance. There can often be a fine line between whether a procedure is considered reconstructive and medically necessary or just an elective cosmetic procedure. 

  5. No referral on file: When required, claims should be filed with a valid referral. This will often be your family physician referring you to a specialist for a needed procedure. Even though the service may be covered by your plan, it can still require a referral prior to the service being done. The insurance company will deny the claim without a referral number. This type of denial can typically be remedied easily by providing the insurance company with a valid referral. How much documentation is required will vary from plan to plan and by the insurance provider. 

  6. Lack of patient progress: Insurance claims for physical, speech, and occupational therapy may be denied due to lack of patient progress. Patients who are receiving long-term care could have payment for the continuance of their care denied due to the insurance company asserting the patient has made only minimal progress as a result of the therapy. Appealing this denial typically requires some documented evidence of improvement from the ongoing therapy. Because there have been many cases of insurance fraud involving providers billing for occupational therapy when no actual therapy was provided, insurance companies heavily scrutinize these claims and can be especially rigid about documentation. An experienced health insurance attorney will help ensure you receive the legitimate therapies or long-term care you need. 

  7. Coordination of benefits denials: Coordination of benefits denials occur when a patient has more than one health insurance plan. There are specific rules that determine which health insurance provider is the primary and which company is considered the secondary or tertiary provider. There are guidelines for billing each provider involved in a coordination of benefits claim. These claims may be denied if an insurer is missing an EOB (estimate of benefits), another insurance company is considered primary, or if they do not have the necessary information about the other insurance company. Appealing coordination of benefits denials can be complicated or may simply require updating an insurer with some missing information. 

  8. Duplicate claims: According to Healthcare Finance News, administrative mistakes by service providers is one of the most common reasons for health insurance claim denials. If a hospital employee mistakenly submits a claim more than once, the insurance company will automatically deny the claim. The same problem occurs if a claim is resubmitted rather than following up on the progress of an existing claim. Errors like these that are not your fault can be difficult to track down because no one wants to accept responsibility such a mistake.  

  9. Patient identifier errors: Insurance companies need an accurate patient identifier to process any health insurance claim. If the company is unable to accurately identify you the policyholder as the patient receiving services, they are unable to make payments. Patient identifier errors may include your name being misspelled, your date of birth on your patient information not matching the date of birth on your health insurance plan, your subscriber number is missing from the claim, or your insurance company account was not updated with your new name after you were married. Simple errors like these can result in a claim being delayed or denied.

  10. Improper coding: There are standard codes used to identify medical services and medical procedures. The system of medical coding is known as the Healthcare Common Procedure Coding System (HCPCS). Changes are made to HCPCS periodically and new codes are introduced on an ongoing basis to cover newly developed procedures. When a claim is submitted with improper coding, it may be denied on the basis of the procedure listed not being covered by the policy. Coding errors are often the result of the service provider or hospital's billing department submitting a legitimate claim incorrectly. 

Insurance Companies Must Explain A Denial

Once a claim is submitted, the health insurance company is required by law to explain in writing why they decided to deny payment. If you are seeking authorization from your insurance company prior to receiving treatment, the company should respond within 15 days. For medical services you have already received, the insurance company should provide a written explanation of their denial within 30 days of receiving the claim. The amount of time you have to request your insurance company make an internal review of the denial varies according to plans. Typically, the time limit for requesting an internal review by the insurance company is 60 days. Some plans allow up to one year. Once a company receives a request from you for an internal review of their denial, they must respond promptly.

If after they have conducted an "internal appeal" the company still chooses to deny your claim, you can file for an external review conducted by an independent third party. External review procedures may vary by state, and some states do not have any external review procedures. If you live in a state without existing external review procedures in place that meet minimum consumer protection standards, the Department of Health and Human Services (HHS) oversees the external review process. 

Appealing an Insurance Claim Denial Can Be Difficult

Insurance billing and payment procedures can be confusing to anyone who does not work in the industry. Appealing a denial requires persistence and a great deal of energy. It also requires an understanding of how to best remedy errors so that the appeal can progress in a timely manner. Knowing who to contact within the billing department of large hospitals and dealing with many different people can be tiresome. Contesting a denial is even more challenging because it often occurs at a time when you are either sick or injured. You do not have to go through this difficult process alone. 

Some health insurance plans have a mandatory arbitration clause. With arbitration, you submit your case to a neutral third party who must consider each side of the claim objectively and make a decision. When arbitration is mandatory, you must go through the arbitration process, but it is not binding. That means your case does not have to end with the arbitrator's decision. If arbitration is voluntary and you choose to submit the dispute to arbitration, the decision may be binding. 

Help Near Me to Appeal My Health Insurance Denial

Many claim denials and payment delays are caused by simple issues that can be quickly identified by an experienced health insurance attorney. A claim denial by the insurance company is not final. The federal government guarantees you the right to appeal a health insurance denial and have the insurance company's decision reviewed by a third party. You can avoid many delays and denials by having a good understanding of your insurance policy prior to making a claim. Detailed records and documentation help build a strong appeal. A knowledgeable attorney with experience in health insurance disputes can provide valuable advice and guidance to greatly improve the odds of a successful appeal. Stop Health Insurance Denial is able to help people located anywhere in the United States with their insurance claim denial appeal. Contact us at 310-695-5241 to discuss your claim and your rights. The available remedies and timeframe of your appeal depend largely on your type of health insurance plan.