A few Typical Health Insurance Denials… and some steps you can take to help them from affecting your claims…
Pre-certification penalty/no prior authorization denials/Percertification Problems Denial
A precertification Penalty is is an amount that an insurance will apply to your repsonsibility if you, or the healthcare facility that you are staying at (hospital, etc), did not take the proper steps to obtain pre-certification from your insurance. Ultimately, obtaining prior certification is YOUR responsibility. Therefore, even if the healthcare facility that you are staying at claims to have an authorization on file, you should probably call your insurance to verify that this is true, and that the authorization in question does apply to the actual surgery or other service that you are going to have done.
Sometimes, if this sort of denial is issued on your claim, you or the healthcare facility can file an appeal with the insurance requesting a retroactive authorization be issued that can be used in place of an a prior authorization. However, be prepared to send Medical records since most retroactive authorziation reviews require that medical records be submitted to the insurance before any attempts will be made to do a review of the claim for reto-authorization. Additionally, some insurances will refuse to issue any retroactive authorization at all and claim that a prior authorization should have been requested PRIOR to the services being rendered. It really depends on the insurance in question and charges in question as to whether a reto-authorization can be issued.
A pre-certification problem denial is similar to a pre-certification penalty but is usually associated with only part of the charges that the insurance is questioning. In cases like this, most or part of the charges on the claim in question are paid but some charges are not paid, and the insurance usually needs more information from the healthcare facility, including, but not limited to medical record information, in order to consider payment on the portion of the charges that were denied.
A no-precert penalty is similar to a pre-certification penalty, or a pre-certification problem denial but typically causes ALL charges to be denied instead of only part of the charges. These sorts of denials can become a big problem over time in certain cases, since YOU may be ultimately responsible for 100% of the charges. Of course this depends entirely on the reason for the denial, if the claim is appealable by the healthcare facility, and is really dependent on case by case information since all cases are different.
No Primary Care Physician Referral Denial
A non-referral denial is similar to a no-precert denial except that it applies to not having a referral from your primary care physician on file with the insurance. Some insurances require referrals to see specialists, and others do not. Please check your insurance policy to see if you need a referral since, as with prior-authorization denials, YOU might be ultimately responsible for payment on no-referral denials.
Timely Filing Denials
Healthcare facilites have a certain timeframe to submit claims that varies greatly depending on the insurance in question, the state in question, and a number of other issues. If the facility waits too long to submit a claim, insurances sometimes deny the charges in question for timely filing. Usually, if it’s the facility’s fault for not submitting the claim, they will have to just take the hit, and not receive payment. However, if you are at fault for some reason, such as not presenting your insurance identification card to the facility at the time of service when you were seen, or you did not give the facility a copy of your insurance information until too late for them to submit the claim in a timely manner, the facility is within it’s rights to bill you for 100% of the charges. For this reason, IT’S ALWAYS IMPORTANT that you present your insurance ID Card to whatever healthcare facility you go to. Your doctors, hospitals, and anyone else that treats you medically really needs to know your insurance information so that they can bill your insurance in a timely manner and not hold you responsible for all charges… Sometimes, it is possible to appeal a denial for late claims, but usually, late claim denials can not be overturned unless there is a really valid reason that the insurance will be ok with.
Sometimes insurances deny claims because they don’t believe that the claim was submitted properly, and they may dispute something on the claim with the facility. Typically this is an argument that the facility and insurance has to battle out between one another because it usually involves interpretion of contracts, laws regarding how things are suppossed to be billed, and other similar issues. If one of your claims, or some of the charges on it ever get denied for something like this, ask as many questions as you can to both the healthcare facility and your insurance so that they can work out the problems as soon as possible and not hold you accountable for something you should not be held responsible for.
Documentation Denial/Medical Necessity
Sometimes insurances deny some or all charges on a claim for need of more documentation. Sometimes this can be as simple as needing a copy of an ER report, itemized statement of charges, or something else out of your medical record. Sometimes it’s due to something the insurance wants directly from you, such as a copy of an accident report from the police, a copy of other insurance information for whatever other insurances you might have, or some form that explains that you don’t have other insurance, etc. Somtimes it’s a lot more complicated than that. If you ever find a denial for need of documenation on your claims, be sure to give the insurance and maybe even your healthcare facility a call to see what additional information is needed, and what steps need to be taken to resolve the issue. Sometimes, the insurance might actually have the needed documentation on file already, but just needs a call to verify this so that they can reprocess the claim(s). Sometimes, for Medical Necessity denials, the insurance just needs a letter from the physician that explains why the charges in question were medically necessary. Always ask questions when you are not certain about why charges are being denied. Many times, documentation denials and medical necessity denials can be overturned with a little bit more information being fed to the insurance by either you or your healthcare provider.
Non-Billable Charges/Non-Covered Charge Denial
Some insurance policies will only cover certain charges. Usually if there is a denial for this sort of thing, you can check your policy and see if the charges of this type are or are not covered by your policy’s benefits. Always be sure to ask the insurance for clarification on something they deny that you do not understand since the processors are human, and prone to human errors on occassion… Many times this sort of denial is applied for certain exclusions to a policy. For instance, your health insurance might not pay for pregnancy of your dependent, etc. Always be sure to read your policy and ask as many questions as you can. It’s good to know what is and is not covered before you go in to see a doctor, have a surgery, etc. so that you can be financially prepared for whatever charges the insurance won’t cover due to some limitation of the plan.
Many insurances have networks of hospitals and doctors. If you see a doctor or go to a hospital in the network, services are paid. If you go to a doctor or hospital out of the network, charges may not be covered, or might be paid at a lesser rate that causes you to be responsible for payment on more of the charges than you would have to pay if you saw an in-network provider of healthcare services. Be sure to check ahead of time that the hospital or doctor that you are seeing is in-network. In emergency situations, sometimes insurances can and will pay in-network rates for out-of-network providers. It all just depends on the insurance in question, their internal policies, and your insurance policy with them. Always ask questions to your insurance if you do not have a clear understanding of something. Also, be sure to ALWAYS give your healthcare provider a copy of your insurance ID card since network logos are sometimes on the cards, and those are useful in helping the facility seek proper payment from the network in question as different networks might pay different rates, or the card might be able to prove that you are in network when the insurance denied the claim saying you were not in network.
No Coverage on Date of Service Denial
This sort of denial is issued when an insurance denies coverage because it believes your policy with them was not active on the date of service. The main times this sort of issue comes up is during extended hospital stays when the insurance coverage stops in the middle of the stay, when a stay extends from December to January and coverage under the policy stops on December 31st, when COBRA is involved but the claim was billed as non-COBRA, or when insurance in question is a special circumstance type of insurance such as Work Comp, an insurance that only covers individuals in prison, only covers a certain population – such as people with aids, etc. However, this sort of denial can really happen in almost any circumstance. If your claim gets denied for this reason, be sure to ask questions to both your healthcare facility and you insurance. Sometimes this sort of denial could have come about from something as simple as the hospital submitting a claim with your old insurance ID number and now they need to submit a claim to the insurance with your new insurance ID number, etc. Sometimes it’s a lot more complicated than that, such as your employer disputing coverage on a work comp case that you believe should have been covered, in which case you ultimately may need to seek legal advice to help get the bill paid. Always ask as many questions as you can to seek clarification on why some or all of a claim is not getting paid if it’s not getting paid.
Certification of Benefits Denial
Many insurances request certain inforamtion from their members about other insurance information, proof of school status, and other such details about once a year. If your insurance requests this sort of information from you, please provide the needed information to them as soon as possible so that your healthcare claims don’t get stuck being non-paid because you did not provide enough information to your insurance to allow you insurance to pay your bill. In cases where claims get held up for this sort of reason, many healthcare providers will hold you responsible for 100% of the charges on a claim, and sometimes even send you to a collection agency seeking payment for the claim. Always make sure your insurance has the information that it needs to get your claims processed.
Sometimes insurances deny claims for need of better coding on a claim. Usually this sort of issue is something that needs to be resolved between the facility and the insurance as it typically involves interpretation of standard practices, contract language, state laws regarding billing, and possibly federal laws regarding billing. Many insurances can and do try to deny claims for coding issues when the claims in question are billed 100% accurately, and the insurance processor did not have a clear understanding of updated laws or regulations about billing that enables them to understand why the claim was coded a certain way. Always be sure to ask as many questions as you can to both your healthcare facility and insurance when a claim gets denied for these sort of reasons. Sometimes the facility is at fault for actually not billing something correctly. Other times the insurance is at fault for not understanding the reason why a facility billed something a certain way. In most cases, you should not be held responsible for coding problems.
Continuation of Stay Issues
Sometimes insurances deny the last day(s) of an inpatient stay, or other facility charge that extends for a number of hours or days beyond what the insurance believes should have been the total length of the stay. Many times, facilities can prove that the extra length of time is justified with proof of medical necessity. Other times, the facility cannot prove that the extra length of time was justified. In all cases where a denial of this sort happens, you should probably request your healthcare facility explain the medical necessity reasons for the extended stay to the insurance so that the insurance can review the facts and determine if additional payemnt is needed.
Cosmetic Surgery Denial
Sometimes, insurances automatically deny anything they believe might be a cosmetic surgery because they believe that the charges in question are not covered by your insurance policy, or that the charges were not really medically necessary. However, in many cases, the charges for surgeries such as facial reconstruction, botox treatments, etc. are needed for a variety of reasons that ARE medically necessary (for instance, perhaps you need a nose reconstruction because it was damaged in a car wreck, a botox injection was given to help relieve pain in a certain area – i.e. it was a bit of a muscle relaxer/pain reliever, etc.), and the healthcare facility can sometimes prove this to the insurance by submitting an appeal on your behalf and/or requesting that the doctor that performed the surgery submit a letter to the insurance on your behalf explaining why the surgery in question was medically necesary. Whenver a claim is denied as being medically un-necessary, it is probably possible to submit an appeal and get additional payment unless you are sure that the charge in question was not really medically necessary and is not covered by your insurance policy (for example you got a face lift or tummy tuck just because you felt like you needed to look better and wanted to look more physically attractive even though your insurance policy specifically says they will not cover charges of this sort)
Sometimes insurances won’t cover hospital or doctors bills that come about due to intoxication. This varies from plan to plan and circumstance to circumstance. Sometimes charges denied for this can be appealed and additional payment is issued by the insurance as a result. Other times, the charges will remain denied since the policy won’t cover the charges in question. Be sure to check your policy to see if it limits coverage for this sort of thing. Also, be sure to be responsible when you drink! NEVER DRINK AND DRIVE! Also, if a third party was responsible for your being hospitalized because they were intoxicated and crashed in to you or something, be sure to ask questions to your healthcare facility and insurance about if the third party will be held accountable for paying your hospital bills. Sometimes, in cases like that, you should seek legal advice…
Mental Health Denial
Some medical insurances deny any charges that are related to mental health because their policies don’t handle mental health and/or there is a mental health insurance that claims related to mental health should be submitted to. However, sometimes this sort of denial is done in error as the charges in question are really medical and not mental. Always ask questions to your insurance, healthcare facility, and possibly even your employer when you receive a denial of this sort to make sure that the correct insurance is being billed and that that insurance will cover the charges in question.
Dental Insurance Denial
Similar to the mental health denials, some medical insurances won’t cover dental related charges. However, in some cases, such as when you are in a wreck and a healthcare provider has to do a surgery to fix something in your mouth immediately to keep you alive, this sort of denial should not be denied and might be appealable so that the insurance can issue additional payment. As with all other denials, make sure to ask questions for clarification as to why the denial is being issued, and if the denial is appealable, or was issued in error.
Sometimes insurances pay the wrong rate for a facility’s claim. If you see the incorrect network discount on your Explanation of Benefits (for instance the insurance took a discount through a network that you know for a fact is not a pricing agency for your insurance), it might be a good idea to call your insurance to see if they need to reprocess the claim. Many insurances utilize multiple networks, and may sometimes pick the wrong network to price a claim. This can affect how much you owe. For instance one network might allow for a 30% discount and another may allow for a 20% discount, leaving you to pay more in your deductible if your deductible is based on a percentage of charges. A 10% difference may not sound like a lot, but if you have a hospital bill worth thousands of dollars in total charges, that can add up fast.
Multiple Dignosis Denial
Some insurances will deny some or all charges for certain diagnosis. If you receive a denial from an insurance, ask the insurance for clarification about why the charges in question are being denied, because sometimes denials are issued in error.
Duplicate Claim Denial
Sometimes insurances deny charges if they receive a bill from the same facility for the same date of service, where there are more than one bill on the same day. Sometimes this sort of denial is valid because the billing department at the facility may have messed up and created two claims when only one was needed. However, other times, this sort of denial can be overturned since you may have legitimately had more than one office visit at the same place in one day. For instance, some people that live far away from a hospital might come in to a hospital with clinics in it and go see one place for an eye exam, another for treatment of flu symptoms, and also have an x-ray done for follow up on a broken bone on the same day, etc. Also, sometimes someone may go to an ER, be released, only to come back later in the day after they have an additional accident or new untreated symptoms arrive, etc.
Emergent/Urgent Care Denial
Some insurances will deny emergency or urgent care charges if they believe the charges in question are related to a diagnosis that they believe did not require emergency care. Sometimes denials of this type can be overturned since the charges in question actually did require emergency care, as the claim itself that was submitted to the insurance did not give the insurance the full picture of what all was going on. In cases like this, sometimes, and appeal with some information from the medical record can overturn the denial and get the claim paid.
Experimental Service Denial
Some insurances deny some charges as being expermental becuase the Amercian Medical
Association, or some other group does not have a lot of information on use of this type of treatment for this type of problem. Sometimes these sort of denials can be overturned. Other times they cannot. Additionally, sometimes, the healthcare facility in question will accept non-payment on certain charges like this since the charges in question actually were experimental.
Maximum Benefits paid for Policy Issue
Some policies have a lifetime maximum payment amount or a yearly, or even daily maximum payment amount. Usually, once the maximum has been reached you will be held responsible for 100% of the allowable charges (all charges left after the network discount is applied). Sometimes, in some rare cases, the maximum policy benefits were not really reached when the bill in question was paid, so the insurance might be able to get some more paid on the claim if you appeal the claim to them asking for further payment. Also, some facilities might be able to do additional discounts for you if the charges in question that you are responsible for if you promise to pay a certain amount in a certain time frame. Ask questions any time something is denied since it might be possible to squeeze more money out of either the insurance of the facility to cover all or some of your portion of the charges.
Some healthcare facilities do write-offs for some individuals who cannot issue payment in some circumstances regardless of whether they have insurance or not… Also some will take a patient responsibility discount if you issue payment to them in a certain speeded up timeframe. It is possible to do some level of negotiation with both the insurances and healthcare facilities in some cases. However, you won’t ever know much about that sort of thing unless you ask the right questions to the right people. Always be involved in your own healthcare, and ask as many questions as you can, both about your actual medical well being, as well as your financial well being. The only dumb question is one that is never asked but that should have been.
Be Proactive. Be healthy. Be wealthy, and be wise.