Not sure where I should post this question. Where can one get advice regarding a health insurance denial - I get different reasons each and every time I call the insurance company. Now I'm told the doctor needs to correct their billing statement! Is there somewhere one can go for advice to insure a claim will be properly coded and paid. The claim is for one of my children and is not MS related. Thanks.
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Ask the claims rep what coding is need for payment. Call the doc's office and request the claim be resubmitted with that particular code.
Also, denied claims should include an explanation in writing enumerating all the reasons for denial. It should not be piece meal, one denial in writing and a different one when you talk with a claims rep. -
What's strange is
they originally partially paid for it (questioned ONE line of the claim) and then rejected the entire claim. Then they withheld monies from an entirely different claim due to the "overpayment" from the first claim even though I, nor the provider, never received any payment for the first claim....Comment
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PS What do you
recommend I do when the denials are piecemeal? ThanksComment
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Sounds like you've entered the deep void, bottomless pit of mishandled, denied claims. One small problem and everything goes down hill quickly, in exponential proportion$.
Charging back a claim that wasn't paid, now that's going to be fun explaining to each new claim rep until it's somehow unraveled.
I think all you can do is join forces with your doc's office and gang up on the insurance company until you wear them down. Also, talk to a supervisor, get their name and make numberous annoying calls daily.
Maybe someone else has a better suggestion.Comment
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Long, but a variety of ideas to try
From someone who was a health insurance executive for 12 years:
You should have an "insurance handbook" or a "benefit plan description" that tells you what sorts of services are covered and not covered. There are often two versions - a relatively plain English version for the patient/insured that you are given at enrollment/renewal, and another version in great technical detail designed for the Employer's HR department, or the government bureaucracy, which you usually have to ask for (though it is apt to be full of incomprehensible jargon). Try to be familiar with what your benefit coverage "should be."
If it is an HMO denial, there is usual a state requirement to explain the appeals process. If you receive a notice telling you how to appeal, follow that process exactly and keep detailed records, copies, names and dates/times of who you contact. Medicare also has an elaborate appeals process for denials, and they also frequently decline to say how the doctor "should" code the claim in order for it to be eligible for payment.
It sounds like this is a clerical error rather than a deliberate denial of a service as not a covered benefit, or you haven't met the deductible. That will require repeated calls and persistence once you understand the nature of the problem/error. With different answers from different people that will be a challenge, but if there is a clear cut clerical error, you usually will prevail eventually.
If there is a good coder/biller in you physician's office, talk with that person. If they outsource that function to another entity, found out who that is and call there. Sometimes the state medical association has people to help their physician members with insurance billing problems, especially if there is one repeat offender insurer causing trouble for many doctors.
If the insurance is through the employment of you or your partner, and that employer is large, well-known and influential, then its HR/health benefits people will not be happy their employee's dependent is being badly treated by the insurer (again especially if there are repeat offenses). Remember that the employer providing the insurance is the real customer, not the patient/family.
In some locations there is a person/company known as a "private insurance adjuster." You hire them and they pursue proper reimbursement for you, in return for a percentage of the payment. This is useful when you have paid a large bill that your insurer should have paid.
Generally insurers must be licensed and follow the laws in your state in order to sell insurance there, and that license is granted and re-approved through the office of the State Insurance Commissioner, or something similar (I believe California has separate divisions for managed care and other health insurance). That office has people on staff who help consumers with insurance company problems - and they are especially hard on repeat violators with many consumer complaints against them.
If your local TV station or newspaper has a "consumer affairs" reporter, that person may help you spotlight a problem, particularly when you are one of many consumers with the same health insurance claims denial problem with the same company.
Your state and federal legislators can be helpful with chronic thorny problems if the above tactics have not been successful, especially if the claim problem involves government programs such as Medicaid, Medicare or S-CHIP (State Children's Health Insurance Program).
Always keep "contemporaneous records" of phone calls detailing date/time/name & title of person you spoke with and the nature of the discussion and any explanations and promises made. Keep copies of all correspondence, and considering mailing things "Certified Mail - Return Receipt Requested." You will need this when/if you go to the Insurance Commissioner's office.
All this takes a lot of time and sometimes some money for those certified mailings. You'll have to decide what the dollar amount is worth to you. But - some insurers are counting on you not to pursue the problem so they don't have to pay the claim. "Rage against the machine!"Comment
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Insurance claim denial
I worked for a major insurance company for many years although not in health insurance. It is my recommendation that you formally file a Notice of Appeal. How to do so should be on the company website or it came with the Explanation of Benefits. Do it promptly as there may be time limitations. If you are still not satisfied, file a complaint with your state Department of Insurance. I know when we got Ins. Dept. complaints that it was a big deal and we responded immediately. Usually the folks at the Dept. of Insurance are very helpful to consumers who contact them.
Good luck.Comment
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Try to make sure the bills are paid.
We let one lapse, and the PT office never billed us for several years.
They finally took their old files, and started with court proceedings to get us to pay. All because they did not get the insurance to pay way back when!
We had to make sure it got paid, and it was not easy.
I make sure all doctor's bills are paid now.Comment
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The health insurance is
self-funded. The State Insurance Department can't force the health insurer to do anything. In fact the insurance company is giving the State the rnaround as well.Comment
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ERISA
Self insured health plans are regulated according to Federal regs under ERISA, or the Employee Retirement Income Security Act. ERISA was initially written to regulate employer sponsored Pension Plans, to protect pension fund assets, employee retirement plan funds.
Since the explosion of self insured/funded health plans, ERISA became the regulating statute, primarily because the funds belong to 'the plan', and the similarities with the funding of pension plans.
DOL, the Department of Labor is the regulating agency for reporting problems with a Self Insured/Funded Health Insurance Plan.
You might find some helpful info by searching Self Insured Health Plans, including your state in the search.
This link might help you:
http://www.insure.com/articles/healt...ed-claims.html
Good luck.Comment
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Most large employers are self-funded but as MSW1963 points out, they still have to obey the law even if it is federal law rather than state.
Multi-state self-insured companies may have to follow relevant state law of the state where the firm is domiciled. Even if it is not your state, State Insurance Commissioners do talk to each other.Comment
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Would you clarify
(MS cognitive impairment kicking in here...), who is responsible for following the law - the health insurance carrier for the self-funded plan, the employer, or both?Comment
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Both, though realistically the employer outsources the administrative services to the insurance company precisely because of their expertise in obeying complex laws.
If it's too complex for large corporations' executives, it's no surprise we're confused!Comment
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Also frustrating is
I get a different answer almost every time I call - I have no idea which is the correct answer. Latest is to have the provider send in a "corrected" bill. What the heck does that mean?Comment
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What you can do is ask for a record of every claim submitted on that service date (when you went to dr) and the reason for the denials (claim codes with explanations). They should be able to print that for you. I'd call back and ask for that - not for an explanation of the denial. Don't give them a chance to argue. Once you have that in front of you, you have a better chance of arguing.Comment
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