The easiest way to resolve a claims dispute is to know what your benefits are to begin with.
Find out why the claim was denied. Are you still covered by that insurance? Did you go to an office out of your network? Did you need a referral? If you’ve ever called and had to wait on hold forever, you know that insurance companies are busy places. Most are understaffed and finding good help is hard-some have even outsourced to other countries. Make sure the person you speak with takes the time to review your benefits and ensures the claim was processed correctly. Some representatives are quick to place blame on the provider’s office that submitted the claim, just to get you off the phone so they can get on with the next call. Even more will swear they never received the claim, although they clearly did since you’re holding the denial in your hand. Before going any further, make sure you understand why it was denied.
Ask questions. Find out what you can do to get the claim paid. You may need a referral or prior authorization from a primary care provider. You may be able to send in a written appeal. You may just need to make a phone call to the doctor’s office. Some clinics have data entry departments staffed with people, not computers, and people make mistakes. A diagnosis code with transposed numbers can easily trigger a denial.
If you need to write a letter, remain professional. Give the facts and an explanation of what happened. Don’t say that the insurance should pay because you pay your premiums, because they’ll tell you that you should also know your benefits. Apologize, if necessary, and…
Remain civil. In any correspondence, by telephone or by mail, stay calm. Don’t swear, threaten, or insult, it won’t change the outcome.
Stay on top of things. Most insurance companies have time limits on how long you have to appeal for any reason, so make sure you follow up immediately. Don’t assume it’s been paid or taken care of just because you aren’t getting a bill. Contact the clinic to find out if they’ve received payment. Keep the office informed of the status on your appeal. Some clinics may hold your bill if you let them know you’re working with your insurance company, but more will require you pay. Once the insurance company informs them the claim is patient responsibility, the clinic is within their rights to bill you. Don’t fight them or harass them about it-they deserve to be paid for the service they provided. If and when your appeal is approved and the claim is paid, you will be reimbursed. (And you’ll know when it’s paid, because you’re following up on it, right?)
Most importantly, learn from your mistakes. If you went to the wrong clinic, check with your insurance before visiting a new office. If it was a non-covered service, check your benefits before receiving the service. Disputing a claim because you didn’t know better is one thing, but try disputing it again because you made the same mistake twice, and you’ll find the outcome very different.