There are numerous reasons why a health plan may deny claims. Some are meritorious, and others plainly fallacious. However, many denied claims result from administrative error by the provider or the health insurance plan. If the coding used to describe various diagnoses and procedures is off by a digit or a character, or lacking a certain extra character (modifier), the claim could be denied. Similarly, hospitals often obtain insurance information from a patient in the emergency room. Sometimes, there is a disconnect between what is given to health care providers. Sometimes, a hospital simply types in the social security number or the name of the patient incorrectly.
Armed with an incorrect address, and unchecked undeliverable mail returned, a provider will often send monthly bills (without response) and eventually send the claim to collections. It is a rude awakening to hear from a collection agency that a bill is unknowingly due and unpaid.
If a pre-authorization requests an incorrect number of days for an inpatient hospital stay, the whole claim is typically denied. Some are denied because an in-network provider discontinued its contract with the health insurance plan yet failed to notify patients and the insurer neglected to update its provider list in a timely manner. *Under The No Surprises Act, insurers are supposed to provide notice to members and continue to pay charges to effect continuity of care for a time after the provider’s contract ended.
Often, it takes time and effort to ascertain what underlies any denial. Often, such ministerial errors can be corrected—and the coverage denial reversed, with conversation and correspondence. At times, misinformation in medical records can cause a domino effect and create a tangle of claims and denials that must be navigated. If this cannot be accomplished otherwise, and when appropriate, we can prepare an appeal on your behalf. We have authored and accomplished many successful insurance appeals over the past 9 ½ years.