October 16, 2018


5 Simple Ways to Prevent a Denied Claim

Everyone fears it: The denied claim. Let's face it. We have all heard the horror stories on television about denied healthcare claims. These stories strike at the heart of our fears. What if we need an operation or procedure performed, and our individual health insurance company returns a denied claim? Worse: What if our son or daughter needs care, and we run into a denied claim.

The Secrets of a Denied Claim

As you probably imagine, the picture is more complex than television and the movies allow one to believe. In fact, providers especially do not want to see a denied claim. And there are many simple ways to avoid a denied claim, so let's explore this issue of the denied claim with an open mind. 

Healthcare providers mainly strive hard to prevent healthcare claim denials before a patient ever starts receiving care? It is a little understood fact of the healthcare industry that part of its success hinges on getting the right authorizations and verifying the patient in question is indeed eligible for coverage. 

1. Know your plan. It is important to know the health plan's requirements. Many patients do not read the handbooks their health plans provide, so they're unfamiliar with the plans' requirements. Consequently, many appeals stem from ignorance. Make sure the treatment you are planning on receiving is covered under your insurance before treatment is received.  

2. Determine if an authorization is required. Also, be aware of the authorization time limits. Know that when you receive a written authorizationon for a specific procedure, surgery or physical therapy, there is usually a “specific time frame” given with a beginning and ending date.   The authorization will not be valid and payments will not be made if you do not adhere this “window of time” listed in your authorization letter.

3. Know the maximum benefit coverage of your policy.  Nowadays there are a lot of chincy policies. Many people who believe they have adequate health insurance actually have coverage so riddled with loopholes, limits, exclusions, and gotchas that it won't come close to covering their expenses if they fall seriously ill. At issue are so-called individual plans that consumers get on their own when, say, they've been laid off from a job but are too young for Medicare or too "affluent" for Medicaid. Many of these policies limit the total coverage to $50,000.00 a year or less which is a pittance if any type of serious illness strikes.

4. Contact the doctor’s office. Before an appointment is made, call to make sure he/she still has a contract with your provider, since the web site or the printed sheet of listing physicians may not always be up to date.  

5.  If you need to be admitted to the hospital. Or go to a clinic for a procedure, always confirm that all of the medical providers [i.e. anesthesiologist, radiologist, hospital, specialist…], including the facility is contracted with your health plan.  The facility or the individual physicians may have their own billing system.  If so, they need to be contracted with your health plan to be considered as an in-network provider. 

                                                   Accuracy Makes All the Difference

On top of that, a claim needs to be error-free and accurate in order for the provider to be paid. This doesn't mean anyone inspects your healthcare claim for smudges and spilled coffee, but the facts need to be correct. Ask your doctor to check diagnosis and procedure (ICD9) codes for accuracy.  

Believe it or not, the majority of healthcare claim denials happen prior to patient care. The culprit: incomplete forms. Wrong information. A misspelled name or failure to fill out a form completely may result in a denied claim. Wrong information gathered at the registration desk has caused more than one stressful evening for a patient. 

After all, John Smith on Werner Road is not the same person as Joan Smyth of Warner Road. One single wrong letter might cause a chain reaction. The good news is that denials based on errors such as these are easily preventable. And easily correctable. 

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