Her insurance denied her medical claim, but she’s sure it was covered. Now what?

Hi Health Insurance Guys!

I need some guidance on how to dispute a medical claim. I have a PPO Blue Shield Individual plan and was recently billed by Providence for a recent claim that apparently had been denied by my plan, but I am sure it should've been covered.

I spoke to Blue Shield and have read my evidence of coverage documents...please help, I pay a lot for a gold PPO plan to ensure I don't get buried by a claim!

What can I do?

Susan

Kyle Iverson: Hi Susan, we're sorry to hear about this, but I do believe we can get you going in the right direction and hopefully resolve this. Medical claims can be complex and very confusing, especially when they are denials like this or higher-than-anticipated bills.

Claims can be due to a variety of issues from clerical errors, insurance miscommunication, coding mistakes, etc. Unfortunately, Susan, they are very common.

Alan Cash: Ugg, medical claims! First things first, in disputing a claim is to understand exactly why it was denied. Insurance companies are required to provide an Explanation of Benefits (EOB). EOBs outline the services being billed and what was covered and what wasn't, and the reason for any denial.

In the 40+ years our firm has seen denials including services not covered under a plan, coding errors or missing paperwork, out-of-network providers used, missed deadline filings and even the wrong insurance billed!

Kyle: Read your EOB carefully, I can't count how many times I have run through EOBs with clients and compared them with itemized bills from the providers to identify discrepancies. Often, a provider will drop a bill significantly when a patient asks for the itemized bill, but you really need to look at your EOB and make sure it aligns with the services you received.

Once you understand the issue, a call to your insurance company's customer or member services is where we start. Susan, you will need your ID number, date of service, provider's name and the EOB for this call.

Often kindness and politeness prevail over these calls; no matter how upset you are with the claim, you will be asking for clarification on the denial and how it can be corrected without filing a formal appeal.

Often, it's a simple fix due to a coding error or somehow the claim being submitted to the wrong insurance company, but either way, it results in the claim being resubmitted and approved.

Alan: Susan, if the initial call does not resolve the claim, you will begin gathering all relevant documentation and notes such as EOBs and denial letters, medical records and doctor notes, itemized bills from the provider, all correspondence with the insurer and, if necessary, HIPAA release forms for your broker or letters of necessity.

Kyle and I believe documentation is key to making a strong case for an appeal.

Kyle: Every insurance company has a defined process for appealing denied claims. You can usually find this information in your EOB. Submit appeals in writing and include clear explanations of why you're disputing. Request for reconsideration and keep copies of everything you submit. Most insurers require appeals within 180 days of the denial. Once submitted, follow up and keep track of calls and progress.

Alan: Sometimes these processes involve bringing in a patient advocate, broker, medical billing specialist or legal aid. There are resources out there, but in general, disputing a claim requires persistence, organization, and a clear understanding of your policy...that's where your broker should help!

Kyle: As frustrating as it is Susan, many claims are resolved in the patient's favor. Take control by being informed, politely assertive, and thorough.