Medical Claim Denials – What Causes Them and What to do About Them

When you are hurt in an accident, you just want to get better and put your life back together. Getting your claims approved by the insurance company is the last thing you want to worry about. Sadly, the insurance companies have only one concern and that is making money. If there is one little mistake, they may not pay your insurance claim, or it could be seriously delayed when you need it most. It is important to know what may cause a denial or delay of a medical insurance claim before you submit it. Doing so gives you the chance to submit the most complete claim possible and lessens your chance of issues.

Duplicate Claims

There are a few different reasons a claim will register as a duplicate. The biggest reason is when a doctor’s office does not get a timely reply for their services rendered and will resubmit the claim. The insurance company will automatically deny the claim at this point. These duplicate claim situations essentially reset the clock on the time it will take to get an approval. It also happened when two different doctors or health care providers make a claim for the same or similar services. Further information may be required before an approval will be issued.

Vital Information Missing

People are often surprised at the real costs of small mistakes like a misspelled name or incorrect birthdate. These seemingly small mistakes can lead to wasted time and money as well as a complete denial. Careful checking and rechecking of your own information before you submit it can save aggravation.

Expired Eligibility

Another easily avoidable mistake is checking the available eligibility. Usually, a medical facility will verify eligibility before they administer services but not always. Mistakes happen. If the services were rendered in an emergency facility, billing could be done later. Another instance is when the patient and practitioner are both unaware that the expiration date has passed and submits to the company as usual. Eligibility sometimes expires between the time the appointment is made and the actual appointment takes place.

Preauthorization Requirements

Another avoidable mistake that leads to medical claim denials is submitting claims for procedures that needed a reauthorization. Procedures such as CT scans, ultrasounds, MRI’s and other radiology services are very expensive. Most insurance companies require a preauthorization for these types of services. Inpatient admissions and certain surgical procedures are often things that require a preauthorization.

Out-of-Network Provider

Your claim could be denied if the services were rendered by a provider outside the insurers’ network for care. This means that your care was provided by a doctor who has not agreed to your insurance company’s terms of payment. Most insurance policies provide some out-of-network benefits but if not, you’ll have your claim denied or be asked to pay a bigger portion of the cost.

Codes Do Not Match

Every medical procedure has a code that appears on the pre-authorization letter patients receive from their insurer. It’s vital that what is billed by the health care provider matches the procedure the insurer previously approved. There are times when they don’t match, which leads to claims being denied. Paperwork will have to be resubmitted with the correct codes.

Submitting a medical claim when you have been hurt is a tentative process. You are hurting both physically and financially and need the money to survive. It is easy to make mistakes and overlook information in situations like this. It helps to keep every expense well documented, including dates and contact information.

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