Common Denials or Rejections
Anyone who has used the healthcare system has probably had to sort through billing issues with their physician or dental office, clinic, or hospital. Due to a combination of aloof patients and disorganized medical offices, key information regarding insurance and coverage can often be lost in the mix, or omitted altogether. As a savvy consumer of healthcare, be a step ahead of the system when it comes to knowing your coverage and ensuring your clinicians are getting it right.
Here are the most common errors made in the exchange of medical information between the patient, medical office, and insurance company. Minimizing these may require a little extra verification and review of Explanation of Benefit (EOB) forms, but could save hundreds of dollars in overlooked, errantly processed claims.
The wrong insurance is billed. As obvious as it seems that this step is at least done correctly, it is probably the most common billing issue that affects patients. By design, it is simple. You give a coverage card to the billing office, they copy it and input that info into their system, and when the time is right they bill the insurance.
But what happens when you switch jobs mid-year, and your doctor, your kids' pediatrician, your family dentist, your pharmacy, and your eye doctor all have the old insurance on file? Even when you give the information to them, they might not get it right on the first try. When you switch your health insurance, be vigilant about ensuring all of your providers get the change right. It could take months.
Wrong insurance part 2. Incorrect insurance is billed for particular procedure. Count yourself lucky if you have one insurance company for every medical service - medical, dental, eye, preventative, pharmacy, etc. Many employers, in an effort to keep a lid on benefits expenses, shop around and find a la carte pricing on all the different services. While it saves you and your company money, it adds a layer of complexity. You may have one insurance for medical, a different administrator for preventative care, and a different plan covering your dental, vision, and drug costs. It is easy for a patient to get these confused, much less your medical office. Make sure that you and everyone in your family understands which insurance is right for which service, and take an extra look at each EOB when you get them. Any rejections for "procedure/service not covered" could be a sign that your medical office billed the wrong insurance on file.
Authorization not obtained. One HMO-era change that stuck was the idea of prior authorization or precertification prior to obtaining service. The idea was that if you, as a patient, needed to call and authorize a service prior to having it done, the insurance company would have an opportunity to steer you to the most appropriate level of care, or in some cases discourage you from having an unnecessary procedure. Today, it typically applies to major procedures and elective procedures.
There can be big dollars at stake if you don't get a service authorized correctly. Know your plan and what is required to be authorized. When in doubt, call your insurance company and ask. The good news is that the hospital and doctor's office has just as much interest in getting an authorization as you do. They would rather be paid by the insurance than to have to call on you after-the-fact for payment. So work with your hospitals admissions or pre-registration department and provide all the information they need. In this case, you are all on the same team, and they can help ensure the prior authorizations are obtained as needed.