Q: What are some common reasons for an insurance claim to be denied? How do I appeal their decision? A: Having your insurance claim denied is a frustrating and sometimes frightening experience. Unfortunately, it is not uncommon. Across the healthcare industry, the average claim denial rate is between 5% and 10% according to the American Academy of Family Physicians (AAFP). Some of the most common reasons for denial:
• Data entry errors (missing or incorrect information) • No prior authorization • Coding errors • Past timely filing limits • Questions on medical necessity • Patient responsibility (Co-Pay, Deductibles, etc.) Many claims that are initially denied can be successfully appealed. Here are steps you can take. Begin with your Explanation of Benefits (EOBs). It will list the reason your claim was denied. You can also contact your insurance company and ask for an explanation. You have a right to this information. Next, check your paperwork for easily correctable issues including the spelling of your name, address, insurance ID number and dates of service. If any of these are incorrect, contact your insurer with the correct information. If it was an error on the part of your doctor or other provider, report the error to them and ask that they resubmit the claim.
If everything appears correct, your next step will be to gather your evidence for an appeal. You will need to show that the services you want covered are medically necessary. Referrals, prescriptions from your doctor and any relevant information about your medical history may help your claim. Enlist your health care providers’ assistance with this step. Armed with this information you are ready to file a formal appeal. The EOB you received from your insurance provider should tell you how to do this or contact your insurance company for guidance on this step.
It is important to keep all your information organized as you go through the appeal process. Take careful notes during every phone call with the insurance company. Note the name and title of each person you speak to along with the date of each conversation. Ask if there is a tracking or reference number so the next person you talk to can easily access your information to help move your appeal along. If your claim is denied a second time, ask how you can take it to the next level. If you have questions concerning Health Insurance including Individual, Group, Medicare Advantage Plans or Medicare Supplements, call me at 440255-2500 or email me at Lmut[email protected] mutskoinsurance.com. I look forward to helping you. Laura Mutsko Mutsko Insurance Services, LLC 6982 Spinach Drive, Mentor, OH 44060 440-255-5700 www.mutskoinsurance.com