Since I don't work in the medical industry any longer, I can share the little secrets to getting your claim paid without the hassle.
Call the insurance and medical facility before you head to the appointment or procedure. Ask the doctor's billing office what codes they will submit for the appointment and procedures? Once you have the list of codes, call the insurance and verify that the doctor, hospital, or facility are in network.
Then check your benefits and see if you have met the deductible and coinsurance. Also see at what percentage the specific procedure is covered at. Give the insurance customer service rep the codes for the appointment and procedures to check if those specific codes are covered. If they are not, then you will need to call the doctor and ask if there are any other codes that could be used.
After you have followed the first step, (or if there was an emergency and you couldn't check before going to the hospital) and the insurance will still not pay the claim do this step. First call the insurance and ask why the claim was not paid. If they say it was because of the code that was used, then ask for the codes that were filed.
Then call your doctor and ask if there are alternate codes that can be used for the procedure. Some codes have alternate codes that are paid by insurance. If there are alternate codes, have the doctor or hospital resubmit the claim with the alternate codes.
When the coding is correct but the insurance will still not pay, you can request the doctor or hospital submit supporting documentation stating that the procedure was medically necessary. Most of the time the insurance will review the supporting documentation or doctor's notes to determine if the procedure was the only course of action that could be taken. It's not a guarantee they will pay, but it will help your case.
Request a review by the insurance in writing. Gather all the information from steps 1-3 and submit it. You could also have your doctor's office submit the review request. The review can take up to 60 days. After the board reviews the claim a final judgement will be made on whether the insurance will pay the claim.
Follow up every week on the claim processing. Write down the date, time, and the name of the person you spoke with at the doctor's office and the insurance company. Write everything down, and follow up. Don't be afraid to speak with a manager if you cannot get answers. Documentation will help you keep everything in order.
Medical claims can be a bear to tackle if you don't know what you are doing. Rely on your doctor and the medical billing office to help when insurance doesn't pay. You will make numerous phone calls, but in the end it could save you thousands of dollars.
To Your Health,