Dealing With A Denied Health Claim

The first thing to understand is this is a contract. It’s between two parties, the insured and the health insurance company. In most instances this contract outlines what coverage there is, how much of the bill the insurance company pays and what services are covered.

Here’s a quick example of how that may work. Let’s say a Preferred Provider Organization (PPO) covers a visit to a doctor in the network with a $60 co-pay. If the insured chooses instead to go to a doctor outside the network, the PPO may only agree to pay 50% of the physician’s bill.

In the case of prescriptions, the plan may cover 100% of the meds if they were prescribed in a network hospital. If on the other hand medications are purchased at a drugstore, they may only offer to cover 50% of the value of the drugs, after the payment of a high deductible.

The health care system is not user friendly and it’s smart to make it a point to read health care policies. As boring as it may seem, the information in it may save time and money later if there’s a dispute with the health insurance carrier.

Keep in mind that the doctor may think a certain procedure is needed, but the health care plan may not cover it. In other words, its not in the contract with the health insurance provider. This is yet another reason to know what the coverage actually “covers.”

Even knowing what’s in the policy doesn’t guarantee a claim won’t be denied. It’s like death and taxes, almost inevitable. There are things that can be done before contacting an attorney.

Do the obvious first call customer service and find out if the claim was denied because of a medical coding error. That happens fairly frequently. If it wasn’t a coding error, then attempt to get an explanation. Here’s where things get a bit sticky.

If it appears the insurer did stick to the terms of the policy, pay the bill. If on the other hand they appear to be waffling and aren’t living up to their part of the bargain this becomes a dispute and information is needed on the arbitration process.

Take time to call the state insurance department as well. They may be able to resolve things if the insurer did break any regulations. If there is no satisfaction and it comes with a huge run around, contact an attorney with experience in settling and/or litigating health care disputes.

If the insurance company is trying for a settlement for a smaller claim, or none at all; are asking for excessive documentation/verification of a claim or asking for resubmission of documents already provided, speak to a competent lawyer who will cut through the red tape and get the matter resolved.

To learn more visit http://www.sharpfirm.com.