Insurance Claims Denial

If someone in Grand Prairie, Arlington, Fort Worth, Dallas, Mansfield, Duncanville, Cedar Hill, De Soto, Irving, Grapevine, or any other place in Texas gets an insurance claim denied they should not simply give up and go away. That is exactly what the insurance company wants you to do.
Depending on the type of claim that you have the process for what should be done next will vary. One thing that should not vary is the first thing you should do. That is to call an experienced Insurance Law Attorney for a consultation.
The Washington Post ran a positive news article related to this subject on March 16, 2011. The title of the article, which was released by the Associated Press is, “GAO report illustrates success rates for appealing denials of health insurance claims.”
The first sentence in the article says, “Don’t take no for a final answer when a health insurer rejects a claim and leaves behind an unpaid medical bill.” The part that says “Don’t take no for a final answer …” is the part to key into. There are often times many things that can be done to turn that no around. This may be as simple as writing a letter or a phone call in the beginning all the way to a lawsuit and judgment.
The article goes on to tell us that as many as 50 percent of some appeals prompt insurers to reverse their decisions, according to a report from the Government Accountability Office.
One thing for the averge insured to be aware of is that different insurance policies and types of claims require different appeals processes. An attorney comes in handy when knowing what the proper process to follow is in any particular situation. One danger is putting off doing anything. Under some plans, there are time periods within which an appeal must be filed, otherwise there is nothing that can be done. What is tricky about this, is knowing the difference between the insurance plans that say you have to follow a particular process and you actually have to follow that process, and the ones that say you have to follow a particular process and it really does not matter whether you follow that process or not.
Insurers frequently deny claims due to billing errors, missing information or judgments on whether care or service is appropriate. This statement in the article seems to ignore the reality that some insurance companies actually deny claims just because they can. And then they hope the person forgets about, gives up, and goes away.
But as the article states, “These denials can be based on mistakes like an incorrect code on a claim submitted by a doctor’s office.” There is a not-for-profit organization named, “Patient Advocate Foundation” that helps people appeal claims denials related to health insurance claims.
As the Patient Advocate Foundation says, you’ve got a lot of people in America who are ultimately paying a bill they don’t owe because they don’t realize it’s an incorrect code.
The GAO studied health insurer rejection rates at the request of Congress, which wanted a better picture of the issue as part of the health care overhaul it passed. The GAO studied data collected from a handful of states and reports done by other agencies. If found that as many as 50 percent of appeals to insurers in Maryland in 2009 led to coverage decision reversals.
In Ohio, 48 percent of appeals to insurance companies led to reversals last year.
The GAO cited a report from America’s Health Insurance Plans, which studied 37 state external review programs a few years ago and found that about 40 percent of external appeals led to the reversal of a claim denial.
But here is the catch to these statistics: “These figures do not mean patients have nearly a 50 percent shot at success if they appeal a denial. The statistics are based on cases appealed, and only a small portion of denials are challenged.”
As the article points out, “There are many times the claim is denied the first go-round to see if you come back and appeal.” A sad way for the insurance companies to do business if you ask this author.
Patient Advocate Foundation, which works in all 50 states, helped more than 17,000 people deal with insurance claims denials last year. A benefit not covered by a health plan is the most frequent reason they see for claim denials.
Coverage parameters can vary widely and they are often determined by the insurance company and the employer that provides group health coverage. For instance, some company plans may not cover Autism treatments or clinical trial enrollments.
Also, it is seen that some insurance companies have tightened restrictions on prescription drug coverage in recent years and added cost control wrinkles like limits on the number of surgeries covered in a year.
This means a breast cancer patient in some cases may have her biopsy and lumpectomy covered but not the reconstructive surgery that follows.
Though this article is dealing with health insurance claims, the reality is that the same techniques and intentions are used in all types of insurance related claims.