Medical bills become a problem after claims have been denied from insurance carriers and paying off the bills becomes a game of negotiation. This is where a medical billing and insurance advocate can help negotiate and appeal medical claim denials.
Why Medical Claims are Denied
Claims may be denied because the insurance carrier decides that it is not medically necessary, the care was out-of-network or experimental, the procedure was done in an inappropriate health care setting (in-home vs. hospitalization), policy cancelled for lack of payment, or paperwork was filed late. Fortunately, the insured and the medical provider can appeal the decision and work towards providing the insurance company the necessary information it needs to cover care.
How to Appeal a Denied Claim
After an initial claim for health benefits is denied, the insured can appeal the decision through an internal and/or external review. To file for an internal review the insured must file the paperwork that the insurance company requires, each insurance carrier has their own process for appeals so make sure to read over the plan explanation of benefits (EOB) to know their system. When making the appeal include any letters from doctors and other documents that demonstrate why a claim should be approved. Proving industry standards, showing how the desired procedure is cost effective and getting letters from doctors attesting to the medical necessity of the care is beneficial during the appeals process. For services that haven’t been received a decision must be made within 30 days after the request and if it is for a service that has been received the insurance company has 60 days to make a decision. If a claim is still denied after an internal review it is time to seek an external review.
External reviews must be filed within 60 days of the date the insurer sent the final decision for most plans, but some plans will allow for 180 days so make sure to read your plan EOB. In urgent situations, when the time it would take to get the decision of an internal appeal would seriously jeopardize a life or ability to regain maximum function, an external appeal can be requested at the same time as the internal appeal. For both the types of appeals it is best to provide organized documentation of the need for medical care and the benefits of it. States can provide an external review process and so does the federal government. Tips to help you during the appeal process are available in Solved! Curing Your Medical Insurance Problems: Advice from MedWise Insurance Advocacy
Getting medical care approved requires bridging the gap between the healthcare provider and the insurance provider as they agree on price points and services that are received. The benefit of a medical billing advocate is their ability to look at each case and help clients build their case to change a denial into an approval or get parties to negotiate to a lower cost point for out-of-pocket expenses for medical bills. Medical Billing advocates are an authentic source of information about the standards of coverage for medical care and the process it takes to get care approved. Medical Insurance Billing Advocates fighting for medical care coverage saves people thousands of dollars while keeping insurance carriers and he
alth providers negotiating for the best care possible.
Happy to Answer Your Questions
Come and hear me speak all about how to keep clients out of bankruptcy and negotiate medical coverage. You can even earn a CFP CUE or CLE Credit…
Tuesday, June 5th at 5:30pm with The Greater Hudson Valley Financial Planning Association
Wednesday, June 13th at 12:30pm with the Bronx County Bar Association