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Posts Tagged ‘denial’

We blame insurance companies for denying claims.

While they are mostly at fault, there are times when the denial is justified.

I filed an out-of-network claim for a client. I looked at all the numbers that have to be on the claim, and they were all there and looked fine. So the claim was filed.

The insurance processed the claim and paid a very small portion of it. That prompted me to take a second look.

It turns out that the diagnosis code on the claim is unspecified gout. The services were an office visit, aspiration (taking fluid out), injection, and a substance that was injected.

The insurance paid for the office visit and nothing more. In this case I cannot blame the insurance. The diagnosis code told them about a gout, but no code to justify the aspiration or the injection. So, I am going back to the doctor and asking about the details and, very importantly, the location of the injection and the location of the aspiration. I would guess that those may have been in two different places, such as a shoulder and elbow.

It is truly amazing what patients have to go through to receive covered medical services.

One large insurance company managed to cross all lines yesterday.

A client called to ask me to look into a pre-authorization denial for medical services that has been ordered by her doctor a few days before. She told me that in the morning of her test the physician’s office called to let her know that her test was denied; therefore she doesn’t need to keep her appointment.

The medical procedure in question is common for people over 40 years old; therefore I was surprised about the denial. Naturally, I called the doctor’s office to find the reason for the rejection.  I was told that they don’t know. Seemed odd, so I took the next step and called her insurance company. As you would expect I wanted to know the reason for the denial, so we can have it corrected, and get this test approved. At first the customer service person didn’t know, so she asked me to wait on the line. It took her some time to get back on the call, and to tell me that no one knows why the test was denied. Their third party administrator (a company who is hired by the medical insurance company to manage certain tests) made this decision without giving any reason.  She suggested that I appeal the decision. Although I have no reservations on writing appeals, as I had done several hundred ever the years, I always have solid reasoning.  Sending an appeal based on nothing seems foolish, so I asked “what should I base this appeal on?”  She had no answer.

This type of insurance behavior is not only unfair to patients, but it is unlawful. State insurance law requires insurance companies to explain, in plain language, why is a service being denied. They are also required to provide information about the appeals process.

In a few days this test will be pre-approved and paid by the insurance company in question, whether they like it or not!