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People pay premiums to health insurance companies. In return, the insurance firms pay medical bills when an insured person falls ill. People have good faith in the insurance companies as they lend helping hand to the needy people. Sometimes, insured people do not get the payment and coverage of medical treatment. If you are also confronting the health insurance denial problem, get the services of an attorney to claim the payment.
It is the legal responsibility of insurance company to give the written explanation of the insurance denial. The explanation also includes the procedure of appealing to restore the coverage. You have limited time to file an appeal. Provide complete documents to a lawyer so he may represent your case confidently.
It is necessary to take into deliberation the reasons for health insurance denial. Accurate knowledge helps you to take healthy measures and prevent denials. The insured person may visit the website of the insurance company or contact the call customer service. You must understand the legal terms and ways to deal with the case. It may happen that the lawyer is not available due to genuine reasons. You should be capable enough of handling things easily. Equip yourself with health insurance denial information to make a strong case.
Table of Contents
Absence of Referral on File
The insured patient should get a referral from their family doctor. It is prerequisite of some insurance companies. The absence of referral on file may cause the rejection of health insurance.
File a Claim Quickly
The patient should file a claim of coverage quickly. Sometimes, people do not know the period of filing application, so they get late. Consequently, they have to bear a loss. No one can turn the bad destiny if you do not file the case within the deadline.
Use Valid HCPCS and CPT Codes
The patient has to use some CPT and HCPCS codes to complete the procedure of health insurance. The system of coding is entitled the Healthcare Common Procedure Coding System (HCPCS). The coding system should stay up-to-date. Any mistake of inserting codes or date result in insurance denial.
Bill Liability Carrier
Some insurance companies would not pay for medical treatment if you injured in an accident until you get the payment from auto insurance.
More than One Insurance Plans
Have you taken more than one insurance plans? Yes! It may cause the rejection of the medical treatment payment. Categorize the insurance companies as primary, secondary, or tertiary to avoid such panic condition.
Non-Covered Services
Some health insurance plans do not cover certain diseases. That is why; companies do not pay for its treatment.
Medical Emergency and Prior Authorization
It is imperative to get authorization from the insurance company before getting the treatment. Many insurance companies include MRI, CT scan, and Ultrasound as non-emergency cases. The patient should obtain prior-authorization to exploit insurance benefits.
Incorrect Information
Incorrect information becomes the leading cause of health insurance denial. An insured person even cannot claim if he/she provides wrong information to hide certain facts.
Take into consideration the following aspects while filling the form:
- Write correct spelling of your name
- Write the correct date of birth
Use In-network Providers
People may not get the benefits of health insurance if they utilize out-of-network services. The claim automatically denied when they go against the clauses of the insurance agreement. The insurance company may not facilitate the insured person if he/she is living in a foreign country and fells ill.
Health Insurance Company rejects the claim when billing specialist does not provide accurate information. Ultimately, the company does not receive the documents. The insured person may get the medical payment after correcting the errors. There is an option of the resubmission to bill the services.
Denied claims mean that insured person cannot receive the medical coverage. The firm raises some serious objections. There could be any reason for the claim denial such as wrong or missing information about billing. Insurance firms explain the core cause for insurance denial.
It is a tiresome and time-consuming process to apply for the denied insurance. The procedure is patchy, steep, and full of complexities. A common person does not know how to deal with legal matters. Do not do experiments because you have already paid the payment. Hire an attorney how has knowledge and experience to tackle the relevant matters amicably.
Understand the Insurance Policy
A lawyer takes into consideration the type of insurance policy before proceeding to the legal forum. He/she draws the line of difference between what the insurance plan covers and what it does not. The legal experts check whether the provider is in-network or not. He/she will also analyze either health insurance plan is yearly deductible.
A lawyer could flag the illegal insurance denial when he/she knows the ins and outs of the plan.
Art of Preparing Appeal
It becomes a difficult task for the patient to prepare appeal form when his neck is already in the deep water. That is why; he cannot take any action against the insurance firm. Lawyer checks the deadline and dispatching date of the denial letter. He/she takes the necessary action for your objectives. Sometimes, the insurance firm gives a little share of the insurance.
Mature Advice of Lawyer
A lawyer is an expert and experienced person who sets you in the right direction. He does not use the emotions but takes into account the facts to handle the dispute. The lawyer asks proof and proper documentation if the company does not pay money for medical treatment.
The lawyer would like to contact the provider and request him to confirm the diagnostic code. It becomes easy to fix the issue if there was a coding mistake. The provider will pursue the case and asks the company to accept your request.
Analyze the Terms of the Health Insurance Plan
It is also good to move to scrutinize the provisions of the insurance plan. If your plan falls within the orbit of the standard of care, the company is bound to deliver payment. Do not forget to consult medical magazines such as The New England Journal of Medicine and The Journal of the American Medical Association. You may know either disease is within the accepted method of care or not. You may also take help from the doctor to know the real phenomenon.
Provide the Information to Reconsider the Appeal
It becomes difficult to get the application approved if you do not know the ground reality of the insurance denial. Get the help of a lawyer who understands the matter deeply. Lawyer writes a letter to the insurance firm to reassess the whole process. All responsibilities fall on the shoulders of a lawyer whom you hire to defense your objectives.
There are numerous categorize of the lawyers. They are specialists in different domains. Hire a lawyer who has deep knowledge about insurance firms, insurance denials, and methods to recover insurance.
Write a “Matter of Fact” in the Appeal Letter
The insurance denial letter generates frustration and emotional breakup. Do not lose heart because you have not lost all the cards. Write an appeal letter to the firm to review the denial. The letter should be simple and contain “matter of fact” instead of a lengthy explanation.
Opening Statement
The opening statement should include the purpose of writing. Get the advice of a lawyer to know how to catch the attention of the insurance company. Do not forget to share the medical condition and its history. Mention the medications that you are already taking. Insurance firms enlist recognized and valid treatment institutions. Provide the required documents if you missed them in the previous attempt. Only use the certified email to dispatch the required information within a deadline.
Every insured person has the legal right to pursue the case at two forums – internal and external. You may ask the company to review the case thoroughly. You may go to the third party for justice if the insurance company is canceling your appeal repeatedly. You will need the help of a lawyer to push proceedings in the court.
You may also request the insurance company to speed the procedure if you are suffering from a critical health problem. It is the ethical responsibility of the company to process as soon as possible.
The insurance company may raise some objections that the doctor has not provided the full-fledged information. You may easily get the problem fixed and send it again to the insurance firm. You are an employee; ask your health benefits manager to contact the insurance company to tell why you need the insurance support. The manager’s call could help to reverse the decision. Do not forget to inform the doctor while filling the appeal form.
It is imperative to keep the record maintain. Write the name of the person, contact no, and date.
A good lawyer knows how to prepare the case. A poor case would give you nothing except a waste of time and money. A common person cannot replace a professional lawyer. Do not keep your money at stake with self-help. An Attorney frames a concise appeal letter and tries until you win the case.
