Ever increasing medical cost is causing insurance companies and medical providers to find ever more inventive ways to cut expenses. Unfortunately, one of those ways is to deny even minor medical claims for patients.
A common reason for a medical claim denial is the determination of whether that claim was a medical necessity. If you visit a primary care Physician or specialist while not experiencing symptoms, or at least symptoms obvious to the medical professional, your reason for the office visit and any prescribed treatment may be found unnecessary. If it is a mild ailment which can be treated with over the counter medications then that maybe the best course of action.
If however, you feel that visiting the medical professional was appropriate and necessary yet you received a bill from the medical provider stating that your claim was denied there are actions that can be taken. All claims should be preceded by an explanation of benefits, also known as an EOB, that should give a reason for the claim denial. Information included on the EOB will also include an appeals process for challenging the denial from your insurance provider.
It is very important to read and save all documentation provided by the medical provider, the insurance company, and any third parties. Often the claim will be denied for no other reason than the initial claim was improperly billed or improperly submitted to the insurance company. Errors occur more often in medical billing then you may expect and verifying what has been billed is an important first step.
If a bill has been submitted incorrectly then the easy solution is to contact the medical provider and have them resubmit the bill. Once the claim has been resubmitted with the proper billing then the provider should be paid by the insurance company and there should be no further issues.
It may not always be that simple and the reason for the denial as explained on the EOB may require more steps and a discussion with your insurance company. It is very important to fully read and understand what services are and are not covered by your insurance plan. Some services require prior authorization or may not be covered at all and the patient will be required to pay the full amount of the service. Often, prior approval is only required for advanced medical procedures or surgeries due to their expensive nature.
Prior authorization is usually required to keep costs in check to ensure patients aren't excessively using medical resources and obtaining unnecessary procedures. If you still feel that it truly is a minor medical claim that would not require prior authorization and is covered by your provider under your insurance plan details, then the appeals process should address the problem.
During the appeals process your medical claim is personally reviewed by individuals in the appeals department to determine the validity of the appeal and whether or not the medical claim should be paid by the insurer. If the appeal process is not favorable, patients are still able to contact their state Department of Insurance to file a grievance.