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How to mitigate and avoid the denial of a health insurance claim

High healthcare costs have become a major concern for consumers and insurance companies alike, with many insurers regularly contesting or denying policy payouts involving a variety of health care claims. Problems can sometimes be avoided by taking the right steps. This article highlights some of the most commonly contested health care claims, and what customers can do to help mitigate or avoid the related problems that often emerge.


Do keep your insurance policy handy

The language in your health/hospitalization insurance policy will determine whether your claim eventually is paid or denied. That is why it is so important to keep a copy of your policy in a safe and easy-to-locate place. If you eventually end up having to file a legal claim based on your denied claim, your lawyer will need a complete copy of your policy in order to effectively represent you in court. It is important that you tell a family member or trusted friend where your policy is located in case you are not able to access the policy yourself because of an injury or inability to retrieve the policy yourself.

Do know if you need pre-authorization for hospital admission

Many health insurance policies require pre-authorization before a patient customer can be admitted to a hospital on a non-emergency basis. It is crucial that you know whether your policy includes this requirement before you check in, because some insurers will delay or even deny claims filed by customers who do not secure pre-authorization beforehand.

Do notify your insurer of hospital admission

If you require emergency hospital admission but are unable to seek pre-authorization, it is important to notify your insurance carrier as soon as possible following your admission. Although pre-authorization delays for emergency services typically violate the Emergency Medical Treatment and Active Labor Act, the best move is to keep your insurer informed about why you were admitted to the hospital and the services you receive.

Do complete claims forms quickly

The clock does not begin ticking for insurers to pay health care claims until a customer files notice that a claim is being submitted. That means if a patient customer waits two weeks to file their claims forms, then they essentially have added at least two weeks to the time they will be forced to wait to learn whether their claim will be paid. This is why it is so important to quickly provide your insurer with claim forms that are completely filled out, including any requested information and related documents. Incomplete claims forms only increase the wait for customers.

Do retain your forms

Your insurer’s decision on whether to pay your health care claim will be included in what are called Explanation of Benefit (EOB) forms. These EOBs contain the insurer’s reasoning for paying or denying a claim, and the language that is included will be crucial in determining whether your claim was handled appropriately. Like your insurance policy itself, it is important to retain your EOBs in a safe, easy-to-locate place that you or someone you trust can access quickly.


Do not assume your payment is correct

Insurance companies are staffed by individuals who make mistakes just like the rest of us, so it is important to make sure that you are not a victim of such a mistake when it comes time to pay your healthcare provider. If you receive notice from your insurer that a claim will be paid, make sure the payment amount matches the amount due on your invoice. It is much easier to correct a miscalculated payment on the front end rather than trying to unravel what happened after submitting an incorrect payment amount.

Do not presume your bill was paid on time

Healthcare providers often enforce hefty penalties for late payments, which is why you need to make sure your invoices are paid on time even if they are paid in full. Many people presume all is well when they get word that a claim will be paid, but late payments can cause substantial headaches. Insurers typically meet payment deadlines, but not always, so keep close tabs on what bills you owe and when they are due so you can guard against related penalties.

Do not presume you are not covered

Insurance customers regularly abandon any hope of getting their claim paid when they receive an Explanation of Benefits (EOB) form that says their policy will not cover a submitted invoice. What many people do not know is that an EOB denial does not always mean a claim ultimately will be denied. While the EOB presents the insurers reasoning for denying your claim, it is possible that your lawyer or a judge and jury may view things differently. In many instances, claims that initially were denied are later paid after an insurer is presented with a cogent argument in support of paying the claim.

Do not Immediately accept a ‘usual, reasonable and customary’ denial

Insurance companies are known for rejecting or reducing payments on health care claims by deeming that the services are not “usual, reasonable and customary.” The end result is that your healthcare provider may look to you to satisfy the balance of an invoice that you thought would have been paid in full by the insurance company. If you receive this language on an EOB form, do not simply accept your insurer’s reasoning as accurate. Contact your healthcare provider and determine if they will write off the balance, and if not, you can challenge the insurance company’s decision.

Do not sign a release or waiver

Both insurance companies and health care providers are afraid of lawsuits, which is why most patients typically are asked to sign a release or waiver of claims before being discharged from the hospital or doctor’s office. Although there are instances in our legal system where releases or waivers have been found to be invalid, there are no guarantees if you sign on the dotted line. It is also worth noting that a signed release can be presented as evidence against you in court. The best advice for anyone who has been asked to sign a release or waiver is for them to contact an attorney before putting a pen to paper.

Jumping cartoon

When a health insurance claim is denied or delayed, it only adds to the existing problems for customers. That is why it is so important to know what your policy covers and the steps you can take to help get your claim paid. A denied claim is not always the final word. By asking the right questions, providing the correct information and consulting a lawyer before signing any type of waiver, you can greatly increase the chances of getting the most benefit from your health insurance coverage.

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Bruce SmithAttorney

Attorney Bruce A. Smith of Ward & Smith in Longview, Texas, represents individuals and businesses in a wide variety of insurance policy claims, including cases when payments have been denied in bad faith for health, homeowner, life and ca...

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