When you receive a bill from a Physician’s office for a visit that you presumed your health insurance carrier would cover, and you disagree, your investigation into the matter commences. Begin by calling the provider’s office, and requesting to speak to the billing clerk who handled your claim. The conversation you have with this employee can clear up initial questions. Often times immediately. If not, then you need to start inquiring why. Such as, did they enter your correct member ID and group numbers from your medical card? Was all the personal information accurate? If all of this was correct, normally the next step is to ask the office if they received an explanation of benefits (E.O.B.) from the insurer that would have denied payment and a reason for their decision. After verifying the basic information and you are still not satisfied, it is recommended that you contact your provider service department at the insurance company. You will need to have at your fingertips, all of your information or any paperwork you received in response to your claim. The company that carries your health insurance will want to confirm with you everything they need so they can assist you. Hopefully, it can be resolved at this level, but often the search for why your claim was rejected by them will need to be reviewed.
If indeed you know for a fact that this bill should have been covered, than the general recommendation is to continue your query. Many people may opt to write a letter to the insurance company and request that they review the claim again.
If the response that your benefit provider sends to you remains unsatisfactory, the issue can be looked into at your employer’s benefits department. Often, the coordinator can assist you in the process. They will be able to determine if the service provided was a covered benefit. Also, they can speak directly to the insurance company and ask questions in reference to your medical condition for which you sought treatment. Sometimes, the answer given by the insurance representative has previously been reviewed, and they deemed your visit was not medically necessary for your condition. If you are denied again, you have the choice to appeal their decision, and many times your doctor’s office will be able to help you with the appeal. Truly, all of this can be quite frustrating. Remember that you have the right to get to the bottom of your issue. You must be your own advocate.
The opportunity to take your case further now, would be to investigate outside resources Examples of who you can contact are; The United States Department of Labor. This office regulates employee sponsored health plans. Also, health advocacy programs are a source of help in these situations. Information can be located by calling the agency directly, or looking for guidance on the internet.
To finalize, it is imperative to understand that human error occurs often in the workplace. There are multiple times that the issue of denial of payment on a claim to your physician, can be examined again quickly and resolved. But, mistakes happen frequently, and if you feel the denial of payment was unreasonable, it is in your best interest to inquire about the matter until you feel content with the outcome.
