By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
November 19, 2024
Sometimes you, the patient, can cause a claim denial.
What are the most common reasons and solutions?
A. Causes for denials
1. Incorrect Data and demographics:
Claims submitted by a medical provider - or you for reimbursement - must reflect accurate information:
· correct carrier: Is it Blue Cross/Blue Shield of Florida, or Blue Cross/Blue Shield of
Illinois? Is it Medicare or a Medicare Advantage plan through Aetna? Your insurance card
will list the right name of the carrier.
· correct ID number: Sometimes every family member shares the same ID number, but
sometimes each one has their own or an additional digit or two.
· identifying the subscriber: that is the person under whose name the policy is held
. identifying the patient: name, address, date of birth and relationship to the subscriber (self, spouse, child, etc).
2. coordination of benefit: your insurance needs to find out whether another policy is
responsible for payment, whether you are a subscriber or dependent. Which one is primary - who will process and pay the claim first - and which one is secondary - they will
process the claim after the primary insurance has issued its EOB - ?
Any incorrect order or missing primary EOB information will result in a rejection, from both plans. Ignoring coordination of benefit is not a choice.
3. not responding to accidents and injuries inquiries. Could someone else be
responsible for payment, such as a car insurance policy, a homeowners insurance,
or any third party liability? Explain how the accident happened, indicate who is
responsible and if someone else might be liable.
4. not indicating claims are due to an accident at work or work-related condition.
This is called "Workers' Comp", and your employer must have a special insurance policy
to cover work-related incidents for employees. If your insurance assumes that this is a Workers' Comp case, they do not have to pay any claim.
4. missing information and or documents: you switched insurance company or plan but
did not notify the provider's biller. You sent an invoice for reimbursement but did not include proof of payment. You did not return a questionnaire, etc. But also, your premiums have not made it - or in time - to the insurance's coffers.
B. Remedies
1. Make sure that all the insurance and demographics information on file with the provider is updated and correct. Confirm premiums have been applied toward your policy.
2. Update Coordination of Benefit info with every insurance plan and communicate with providers the right billing order. Unfortunately, the order is not your choice or preference. There are very strict rules as to who is first, second and so on. For example,
Medicaid usually is always last, but Medicare can be primary or secondary. Your
children's order of insurance may depend on each parent's month of birth, not year. If you have two employers with two different plans, the enrollment start date could
determine which one is primary and which one comes next. The good thing is, if you tell each insurance company about the other(s), they will be talking to each other to determine the correct order.
3. Call in, fax, email, snail mail, send a message through the online portal, or even
send a pigeon carrier, but respond to any questionnaire your insurance sends you. Down the line, maybe 30 days later, make sure that any denied or rejected claim has
now been processed.
4. For accidents or injuries, indicate which 3rd party might be responsible or liable - for example, another driver. If unsure whether their insurance will cover your
medical bills, or if the supermarket where you slipped and fell will accept any kind
of liability, indicate so, as well as any attorney's contact info if involved. Your plan
can pay the claims for an accident, then get reimbursed later, when or if you receive a
settlement.
5. Workers comp claims are a little bit different. Your employer becomes liable for your medical bills, not your health insurance, but for that, you will need to open a claim with the workers' comp carrier directly. Your health insurance will recoup payments made on your behalf, if the case proves to be workers' comp. Because the process of
getting paid is trickier and often delayed, many medical providers do not accept
workers' comp cases. Make sure your provider does to avoid getting billed later, once your medical policy recoups their payments.
C. Tips
1. Trust but verify
I know you shouldn't be doing this follow up work. This is the office or insurance's job
but when you give information to someone and a system has to be updated, I always follow up. If the office receptionist took a copy of your new insurance card, was the biller notified?
If you updated the Coordination Of Benefits with the Eligibility Dept, has the Claims system been updated?
2. Timeliness is not your friend. Return questionnaires within the 15 or 20 days indicated.
If you don't have answers, send it back with a note explaining why and when it can be expected.
3. Keep a log. Who did you speak with? When? What did you request and what did they say they'd do? Evidence is power in my book: showing that someone who knew did not doing their job, may well be the difference between getting that claim paid or you getting another bill.
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.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024™
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