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"Denied" claims: the many Reasons...and Solutions

Updated: Sep 15, 2023


reasons and solutions for Denied claims
reasons and solutions for Denied claims

By Martine G. Brousse

"The Medical Bill Whisperer... and insurance stuff too"

Patient Advocate, Certified Mediator

AdvimedPro


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August 22, 2023


I cannot count the number of calls, emails or posts I have seen that lament “the insurance has denied the claim”, and the ensuing responses of frustration, anger and outrage.

While I am not one taking the side of insurance companies (I fight them for a living!) it must be pointed out that there are a fair number of reasons why non-payments could be legitimate.


To start with, is the claim truly “denied” or merely “unprocessable”?


Let’s sort it out.


A. Deductibles and Share of Cost


I have written a detailed blog on this subject, but to recap it:

· Your insurance will only start making payments once your Deductible has been met.

· You may have 2 separate deductibles: In Network and Out of Network.

· Your insurance’s EOB (Explanation Of Benefit showing how it processed charges) will reflect the amount applied toward this liability.

· You can confirm the claim is NOT denied because it will show an “allowance” meaning an accepted responsibility to pay the provider. That you must first make that payment is part of insurance policies.

· After you meet the deductible, you will likely still be liable for a portion of the “allowance”, called “co-insurance” (or “out of pocket”)

· Only after you meet both your deductible and “co-insurance”, will your insurance cover those allowances @100%.

· Note: Out of network allowances will be much lower, leaving you with a large liability.


If your EOB shows a $ 0.00 payment on the part of the insurance, and that the “allowance” amount is listed under your deductible, it is likely correct and there is nothing “denied”.


B. Provider errors


There are many instances where the insurance must reject a claim from a provider because of incorrect coding, incomplete information or missing documentation.


1. Demographics errors:

· wrong date of birth, or incorrect spelling of name

· incorrect insurance ID#

· incorrect insurance info or insurance order (if you have 2 policies)


2. Coding errors:

· Diagnosis code does not match the procedure

· Missing number of units or missing modifier (technical but essential stuff)

· Wrong date of service or place of service

· Missing provider info (tax ID# for example)

· Procedure inconsistent with the type of professional license (a speech therapist billing for a “MD visit" instead of "speech therapy session" for example)


3. Administrative errors

· Untimely filing (claim filed too late)

· Missing documentation or medical records

· Non-response to insurance’s request for those medical records

· Lack of an authorization

· Missing primary insurance EOB (when billing the secondary carrier)


C. Patients’ errors


· Failure to communicate updated demographics or insurance info to the provider

· Failure to respond to insurance’s questionnaire regarding other potential insurance policies (“Coordination Of Benefits”)

· Forgetting to tell the provider you have more than one policy

· Not responding to insurance’s questionnaire regarding an accident or circumstances leading to an ER visit

· Not alerting HR or insurance of change in the family (new baby, child getting own plan)

· Not paying the premiums resulting in the insurance pending processing of claim or cancelling your policy.

· Not being aware that a 26-yr dependent, even if still a student, will automatically be removed as a covered member on your policy


D. Policy /Billing Guidelines


· “Inclusive”: if a procedure is considered part of a larger or main procedure, which is being paid separately, an insurance can and will reject it. You should not be liable and the provider should write it off. Examples: a venipuncture with a lab, a post-op visit after a surgery.

· “Not a covered benefit”: either it is not a charge that your policy pays for (over-the-counter Rx for example) or because it is listed as a specific exclusion (infertility treatments, caregiver services, etc)

· “Outside of area”: if the provider bills your assigned medical group for services that the healthplan should cover, or vice versa, you could see this notice. The provider must bill the other entity to get paid.

· “Services not required”: often seen when an assistant surgeon bills for a minor procedure, it means that the provider should have included medical records showing the need for the service (for example: an emergency developed and a more complicated surgery took place)

· “Not medically necessary”: usually, it means that the insurance did not receive enough or any medical justification for the service before it happened, or at the time of billing.

· “Investigational or experimental”: often it is a mere coding error but it could be a graver issue (non FDA-approved use of a drug or treatment, patient’s medical situation not justifying a genetic test etc)

· “Not authorized”: either the provider did not request a necessary authorization, or the request was not granted

· “Pre-existing”: although rarely seen, it means that the diagnosis used to bill the service is excluded from coverage, unless proven that it is new or acute.

· “Primary EOB missing”: the provider billed the secondary policy without attaching the primary insurance’s policy showing how much you owe.


E. Solutions


1. Know your policy!

· Find out how much your yearly share of cost it, either on your online portal or by calling your insurance

· Keep track online or with a call

· Audit EOBs, especially Out Of Network ones to make sure what should be paid was (see blog on “In vs Out Of Network”


2. Contact the office/billing service

· to update demographic and insurance information

· to have charges corrected when due to coding errors

· to ask for prompt submission of medical records

· to ask whether a needed authorization was obtained, if not then why not, and how the issue will be remedied. Retro-authorization requests can be filed, or an appeal.

· to make sure any request from the insurance has been complied with (medical records, primary EOB etc)

· to find out what needs to be done, by whom and how, especially if an appeal must be filed.


3. Communicate with your insurance

· Update any necessary info over the phone or online if you can’t find or did not receive any questionnaire

· Add or remove dependents right away

· Set up automatic premium payments to avoid a suspension or cancellation of your policy

· If your 26-yr old is still a student, consider buying a student insurance policy.

· If your 26-yr old is not a student or does not get insurance through work, you will need to purchase a policy on the open market, either through an agent or an Obamacare Exchange.


F. Important Tips:


1. Check your liability on any legitimate EOBs. If it says $ 0.00 but you receive a statement from the provider, complain to your insurance right away. They need to contact the office or billing service to get that stopped

2. If your liability shows as the full amount (or allowance amount) but it is not your fault, complain to your insurance right away. They can change the EOB to reflect you should owe nothing.

3. If the insurance has sent you a copy of an authorization letter or other approval correspondence then denies for lack if it (happens way too often!), make a call to get the matter corrected or send a message through your online portal. It should be quickly resolved.

4. Do not think that you can decide which insurance to use, or which order of policy you might prefer. This is NOT your choice! There are legal mandates which set up which policy comes first, whether they end up paying anything or not. You will be liable if the provider cannot get paid due to your non-compliance.



Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances and lives.

(424) 999 4705 - F (424) 226 1330

@martine brousse 2023@ the medical bill whisperer 2023


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