Adria Gross is CEO of MedWise Billing,  Inc., a medical-billing advocacy  company based in Monroe that assists  health insurance customers in disputes  with their insurers. She previously  worked as a claims examiner with  Blue Cross/Blue Shield and American  International Group. Info: www.

By Adria Gross

Every time you make a claim under your health insurance policy, there is a substantial possibility that your insurer will decide to reject it.

When claims are rejected, policyholders must either pay out of pocket for medical bills or spend an inordinate amount of time battling a corporate bureaucracy about complex insurance issues that they do not fully understand.

The more you know about how the system works and what you can do to make it work better for you, the more success you likely will have. Here’s how to reduce the odds that your health insurance claims will be rejected—and what to do when a claim is rejected.

If a claim is rejected, investigate why the claim was rejected before paying a medical bill out of pocket. There might be a way to get your insurer to pay it after all. Possible problems and solutions include:

Problem: The health-care provider entered a billing code incorrectly.

Every medical procedure has a five-digit Current Procedural Terminology (CPT) code. Every medical diagnosis has a specific code number, too. If your health-care provider enters a procedure or diagnostic code incorrectly—which happens with surprising frequency—your insurer isn’t likely to waste time trying to figure out what’s wrong. It If Your Health Insurance Claim Is Rejected…will just reject the claim.

What to do: If you believe that a code-entry error might be responsible for the claim rejection, present your concerns to the healthcare provider’s billing department and ask it to resubmit the bill to your insurer with the correct codes.

Problem: The health-care provider billed under the wrong insurance policy.

This is particularly likely if your insurance recently has changed, or if this is the first time that you have received treatment from the health-care provider.

What to do: When an insurer rejects your claim, confirm that the policy number and group number on the paperwork corresponds with your current policy.

Problem: The insurer continues billing you after you’ve met your deductible and/or out-of-pocket maximum.

If your insurer fails to properly track the medical procedures that you have had and/or the payments you’ve made during a year, you might be asked to pay more than you should.

What to do: Keep a file each year of your medical bills…health insurance Explanation of Benefits (EOB) statements…and a tally of the amounts you pay out of pocket.

When you believe that you have reached your annual deductible and/or out-of-pocket maximum, make sure that the insurer doesn’t keep requiring you to pay more. If it does, ask the insurer to review its records and to explain why its tally doesn’t match yours. Keep in mind that the insurer may not count the full amounts charged by out-of-network providers.

Problem: It isn’t clear why the insurer won’t pay a claim.

Insurance company claim rejections can be very difficult to understand.

What to do: Call the insurer’s customer service department, and ask for a plain-English explanation of why the claim was rejected. If you don’t understand or don’t agree with what you’re told, ask to speak with a supervisor. If the first person you speak with doesn’t provide clarity, call back repeatedly and speak with a different representative and supervisor. Take notes documenting the time and date of each call, the person you spoke with and what you were told.