Handling A Denial of Claim - One Agent's Story
February 1, 2012
I'll be the first to tell you, I do NOT like hassles. And I don't particularly like confrontations either. So when the Explanation of Benefits form (you know, that "This is not a bill" thing from your insurance company) for my husband's recent annual checkup arrived showing several segments of the claim denied, I cringed. Before long, the bill from the doctor's office arrived, showing a balance due. Yuck.
In all honestly, I was sorely tempted just to pay it and be done with it! But then I realized that this would be a good learning experience that I could share with my clients and my newsletter readers. After all, I've always preached not to take a denial of claim as the final word.
The final resolution isn't in yet, but this is how I've set the query in motion for clarification so I can either accept it or continue appealing the decision:
1) Using the Explanation of Benefits (EOB), I called the insurance company and had them explain exactly what the various diagnostic codes meant. By the way, these diagnostic codes are assigned by the doctor at the time of the visit. They're on that sheet you carry up to the front desk at the end of the visit. On the EOB, they were just broadly labeled "laboratory" and one was labeled "diagnostic," which didn't give me much to go on.
2) The insurer's member (or customer) service agent was able to expand on what the codes actually meant and even gave me a little extra information like "yeah, that code is so general it's almost always denied" or "that's coded as a diagnostic service - an EKG, specifically - for hypertension rather than preventive."
3) The CSR also shared with me that some of the items that are normally automatically declined would probably be "forgiven" by the insurance company (YES!), but we needed to get clarification - and possible re-coding - on the "diagnostic" portion first. (Not sure why that is, but okay, I can live with it for now. I wasn't looking a gift horse in the mouth - so to speak - at that point.)
4) Armed with this information, I called the doctor's office armed with information. As of right now, the "diagnostic" EKG is being run by the doctor to see if he will reconsider the way he coded it.
What have I learned from this so far? Well, I will be sharing with the doctor's office (probably via letter to the office manager and the billing department) that there are certain codes that probably just shouldn't be used. Like "#80050 - General Health Panel" which apparently means nothing to my insurance company.
And I'll tell the doctor, too. Our doctor is wonderfully cooperative, always open to a discussion of whether a specific test is needed, or whether a generic will work just fine, and so forth. But if I don't let him and the rest of the practice know when and why a claim is being denied, how can they fix it - both for Bill and me, but for other patients?
No matter which way this all lands, I've found it both instructive and empowering not to just stick my head in the sand and pay the bill. I've learned a little more about how the "system" operates and have picked up knowledge that has been useful to me and that I hope will prove enlightening to my clients. That's time well spent!
In all honestly, I was sorely tempted just to pay it and be done with it! But then I realized that this would be a good learning experience that I could share with my clients and my newsletter readers. After all, I've always preached not to take a denial of claim as the final word.
The final resolution isn't in yet, but this is how I've set the query in motion for clarification so I can either accept it or continue appealing the decision:
1) Using the Explanation of Benefits (EOB), I called the insurance company and had them explain exactly what the various diagnostic codes meant. By the way, these diagnostic codes are assigned by the doctor at the time of the visit. They're on that sheet you carry up to the front desk at the end of the visit. On the EOB, they were just broadly labeled "laboratory" and one was labeled "diagnostic," which didn't give me much to go on.
2) The insurer's member (or customer) service agent was able to expand on what the codes actually meant and even gave me a little extra information like "yeah, that code is so general it's almost always denied" or "that's coded as a diagnostic service - an EKG, specifically - for hypertension rather than preventive."
3) The CSR also shared with me that some of the items that are normally automatically declined would probably be "forgiven" by the insurance company (YES!), but we needed to get clarification - and possible re-coding - on the "diagnostic" portion first. (Not sure why that is, but okay, I can live with it for now. I wasn't looking a gift horse in the mouth - so to speak - at that point.)
4) Armed with this information, I called the doctor's office armed with information. As of right now, the "diagnostic" EKG is being run by the doctor to see if he will reconsider the way he coded it.
What have I learned from this so far? Well, I will be sharing with the doctor's office (probably via letter to the office manager and the billing department) that there are certain codes that probably just shouldn't be used. Like "#80050 - General Health Panel" which apparently means nothing to my insurance company.
And I'll tell the doctor, too. Our doctor is wonderfully cooperative, always open to a discussion of whether a specific test is needed, or whether a generic will work just fine, and so forth. But if I don't let him and the rest of the practice know when and why a claim is being denied, how can they fix it - both for Bill and me, but for other patients?
No matter which way this all lands, I've found it both instructive and empowering not to just stick my head in the sand and pay the bill. I've learned a little more about how the "system" operates and have picked up knowledge that has been useful to me and that I hope will prove enlightening to my clients. That's time well spent!
Posted by Sharon Nuttall. Posted In : Claims
704-464-8040
sharon(at)ehealthinsurancesolutions.com
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