Health Insurance: What To Do If They Deny Your Minor Medical Claim

Has your minor medical claim been denied by your insurance company? Find out what you can do about it.

Today, the rising cost of health care is causing a major financial crunch on insurers and employers alike. For this reason, insurance companies will try to find any reason possible to deny your medical claims, regardless of how minor the claim may be. However, there are ways to help prevent claim denials, and the burdensome bills from your doctor's office.

For starters, you should be a wise consumer when it comes to deciding when to visit your doctor. One of the main reasons insurance companies will deny a claim is for lack of medical necessity. In other words, unless you are experiencing symptoms that seem major to you, you should try to take care of your medical needs with the use of over the counter medications. Many times these products will alleviate or cure the problem at hand.

If you visited a doctor and receive a bill for the services rendered with a notation on the bill that reads "Your insurance has denied the services; please pay" the first thing you should do is contact your insurance carrier. Often times they will send you and EOB, or an Explanation of Benefits. This is a statement that outlines how they processed your claim, and should include the reason for denial. In the event you do not receive such a notice, call them. They will explain why the claim is denied. The next step is to determine how to handle the denial.

Sometimes, the reason for the claim denial is of no fault of yours. Many doctors' offices today do not bill out claims. Instead they hire a billing company to submit claims for them. This helps relieve them of some of the administrative burden of running a practice. On occasion, the claims are billed incorrectly, or coded wrong. For example, you visit a podiatrist for foot pain, and they bill a chest x-ray instead of an office visit. The insurance company will see this and will deny for lack of medical necessity, and they should. This is a simple fix. All that has to be done is to have the claim resubmitted with the proper coding, and the claim should pay.

Keep in mind however it is not always the doctor's fault. With so many managed care plans in existence today, it's important to understand how your plan works. If you are enrolled in an HMO (Health Maintenance Organization), the plan states that you must obtain a referral from your PCP (Primary Care Physician) to visit a specialist such as a Cardiologist or a Dermatologist. If you see a specialist with out a referral, the insurance company will deny the claim. The reasoning behind these denials is due to the fact that your PCP is the gatekeeper of your medical care and must be involved in all medical decisions. The only exceptions to this would be in the event of a medical emergency. For these cases you simply go straight to an emergency room for medical care. So always visit your PCP first before deciding to see a specialist.

If you have met all of your insurance company's requirements and still received a denial for a minor medical claim, talk with your carrier and request an appeal. Most insurance companies have not one, but a three step appeal process for you to take advantage of. The good news is that most minor claim denials are eventually reprocessed and paid out, leaving you with only a small copay as your responsibility. This copay is usually paid by you at the time services are rendered.

Finally, when all else fails, you can contact your State Department of Insurance for help. If there is one thing that insurance companies want to avoid that would be complaints against them with the State.

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