How to Handle a Health Insurance Claim Dispute

Today, the majority of doctor office claims are filed on behalf of the patient by the doctor’s office and the same is true for hospitals. Paper claims have been replaced by electronic claims and whatever information is entered on the medical bill is the information that is sent to the insurance providers.

If your name was spelled incorrectly or if your spouse was incorrectly listed as the primary insurance (and it’s not), the claim will be denied. If your birth date was entered incorrectly, your claim will be denied. These are the simple entries that can derail a claim; there are more complex entries that can get that claim rejected in a flash.

Insurance claim disputes usually have a simple solution and the majority of denials for payment get resubmitted without the patient getting overly involved. That’s because the doctors office get the same E.O.B.s (Explanation of Benefits) as you do. There are some claims that need patient involvement and correction before they can be resubmitted for payment.

If your insurance claim was filed from your doctors office, your denial of payment arrives with all the other regular payments. The office I worked for routinely reviewed the denials for errors. The billing and financial staff handle insurance claims everyday and often can spot a problem, correct it and resubmit the claim before you make a call to the insurance company.

Common reasons for non-payment of claims:

*Deductible has not been met. PPO, POS and Medicare have deductibles that must be met before payment on claims begins (HMO has no deductible). Your E.O.B. has a code that will give you the reason.

*Husband and wife are both insured, but the primary insurance belongs to the spouse of the patient. The claim must go to the primary insurer first.

*When patients don’t update their current insurance information with their primary care physician, the claim may be sent to the old insurance on file with the office.

*Patient failed to obtain a referral for specialist services. (HMO)

*Error in the electronic claims transmission.

*Error in the diagnosis code the doctor submits or in the data entry of the code.

Your first line of defense is the doctor’s office that filed the claim. They will be able to find the reason or error in short time.

Sometimes, it is necessary for the patient to call their insurance carrier but if you call the doctor’s office first, they can find the problem and help you resolve the problem without hassle. It’s important to have the E.O.B. handy when you call about a dispute in order to expedite the process.

HMO providers are strict about using the medical and lab services within the provider network. If you go to a service outside of the network your claim will be denied unless it is a medical emergency. This claim is usually not negotiable except in the case of an emergency procedure or while traveling out of the range of your referral.

If you have a claim dispute, call your doctor’s office first. They can supply all the information you need to resolve the dispute and often, they can resolve it for you within a matter of minutes.