Nobody likes to be in a fight alone. We can amplify this a hundredfold when it’s in reference to medical bills and the decisions of large corporations trying to maintain a bottom line. When an insurance provider rejects a claim, and you find yourself in negotiations, you want someone to provide you with the best information to advocate for yourself and your wallet.
Reasons For Medical Claim Denials
There are plenty of reasons an insurance company might reject a claim:
- Out of network care or tests
- Improper treatment plan (ie in-home vs hospital)
- Canceling policy because of a non-paid procedure
- Late filing of the paperwork
This isn’t the end of the road, however, and there are appeal procedures in place to ensure you’re not denied the care you are entitled to.
Claim Denial Appeals Process
The next step after the initial application for health benefits has been rejected is to take advantage of internal and/or external review processes for the decision. In the case of the internal review, it is up to the insured to follow the procedures laid out by their provider, including submission of all necessary paperwork. To find your provider’s procedure locate the benefit description (EOB) of the plan to make sure you understand their system and any required documentation, including records or letters from physicians that detail why they should accept the appeal.
During the appeals process, the following can be beneficial:
- Letters from physicians demonstrating the medical need
- Establishing the cost-effectiveness of the proposed treatment
- Proving Industry practices
If the patient is waiting for a treatment decision, there is a thirty-day time limit from the day of the request. If the service has already been administered, there is a sixty-day time limit on the insurance provider’s decision. If the internal review ends in a rejection, then we move on to the external review.
External Reviews And Negotiation
The time limit for the insurer on most policies is within sixty days of submission; however, there are plans allowing for 180 days to go through your EOB contract. While these limits are in place, there are factors that necessitate a final decision sooner; therefore, it can be necessary for an external review to run concurrently with the internal review. This is obvious in cases where timeliness affects the life or health of the patient.
No matter what the final appeal decision is, it is in the best interests of each party to reach an agreement between the healthcare provider and the insurance provider. This means agreement on price points and facilities at least. Medical billing companies are at an advantage in these scenarios due to the sheer volume of experience. Experience can mean the difference between reversing a rejection or not and/or settling for a lower out-of-pocket cost.
Medical billing companies hold vast knowledge of the processes needed to obtain approvals or reduced out-of-pocket expenses for healthcare. This knowledge on the behalf of patients saves thousands by making sure the best terms for all parties are reached and quality care is achieved as affordably as possible.