Sapiro Law Office

Insurance Benefits Denials

Patient Balance Issues

1. Balance billing by the medical provider
2. Negotiate the balance owed with your physician

Mistakes are often made by the Physician or his/her medical billing office. If you were balance billed for the difference between your contracted health plan and the amount of the payment, this is incorrect. If you pay cash or owe a significant amount, attempt to negotiate a discount or payment plan.

Cash Pay Negotiations / Uninsured Patients

1. Uninsured patients should never pay the full charge
2. Negotiate the balance owed with your physician

Health plans don’t pay the full charge to a medical provider and neither should you. There are a variety of ways to either reduce the total amount you owe or increase the time you have to pay the outstanding balance.

Usual and Customary/Out of Network Denials

1. Usual and Customary Reductions
2. Patient received unexpected bill by an out of network physician

This is probably the most common concern among patients. When a patient goes to a hospital which is contracted with their health plan and feel everything was taken care of, but then they receive out of network bills from the anesthesiologist, pathologist, radiologist, assistant surgeon and so on, which are reduced in payment due to Usual and Customary.

Health Plan Denied the Claim due to Medical Necessity

1. Denial due to lack of medical necessity
2. Experimental/investigational denials
3. Cosmetic denials

A significant number of claims denials are related to medical necessity, or the lack thereof. The health plan is essentially saying that the physician or medical provider that treated you did so without a justifiable medical reason, or that it was cosmetic, experimental, or investigational. But, your physician may know best and if your physician properly documented his/her treatment of you in your medical chart, then this should always be appealed.

Lack of Authorization Denials/Non Participating

1. Non participating services received without a referral or authorization
2. Non participating provider denial

Some health plans, especially HMOs, limit the availability of Specialists to their members, unless they seek an authorization or referral from their primary care physician. This is done so that Specialty Care is not overused or used unnecessarily, as the cost of Specialty Care is expensive.

Emergency Room Denials

1. The health plan denied the Emergency Room visit
2. The health plan denied the transportation to an Emergency Hospital
3. The health plan did not authorize the emergency visit

Physicians and their billing offices must input all of the billing data into their billing system in order to submit a claim to your health plan. During this process, a physician who may have been extensively trained in practicing medicine, may not have been as trained on preparing a bill to the health plan. As a result, mistakes may occur in the preparation and billing of your claim.

Surgical Weight Related Denials

1. The health plan denied a lap band surgical procedure
2. The health plan denied a gastric bypass surgical procedure
3. The health plan denied an abdominoplasty

Health plans do not want to approve a claims payment for medical procedures that they feel are not medically necessary or potentially cosmetic in nature. The method of appealing these are to specify medical reasons of why the surgical procedure is required.

Timely Filing Denials

1. The health plan denied a claim that was billed on time
2. The health plan denied a claim that was not billed on time

One of the most common health insurance claim denials are those that are denied for being submitted late. These can be appealed and won. Some of the claims may be denied in error and you would need proof of the original claim submission to appeal.

Denials Related to Prescription Drugs

1. Drug is not on the health plan’s formulary
2. The health plan denied authorization for prescription drugs
3. The health plan did not pay adequately compared with AWP

Health Insurance Companies have noticed a significant increase in the payments they have made towards Prescription Drug claims. With this in mind, Health Plans have had to be creative in how they attempt to cost contain this benefit coverage.

The Health Plan Processed the Claim Incorrectly

1. The health plan paid the incorrect amount
2. The health plan paid the wrong person or medical provider

Today, many claims payments are made automatically, but still quite a large number of them are processed manually. Due to this manual processing there are opportunities for making a mistake. Some health plans have a better quality rating than others. While one health plan accepts only a 2% error rating, other health plans may be ok with a 20% error rating.

The Physician/Medical Provider Billed the Claim Incorrectly

1. The wrong diagnosis, procedure code or place of service was billed
2. The wrong modifier or lack of modifier was billed
3. The claim was billed without a provider number

Physicians and their billing offices must input all of the billing data into their billing system in order to submit a claim to your health plan. During this process, a physician who may have been extensively trained in practicing medicine, may not have been as trained on preparing a bill to the health plan. As a result, mistakes may occur in the preparation and billing of your claim.

The Claim Denied due to Policy Limitations/Guidelines

1. An authorization was not obtained
2. The claim was filed late, causing a timely filing denial
3. The claim was appealed late, causing a timely follow up denial
4. The claim was denied due to pre-existing
5. The claim was denied due to a duplicate claim previously billed
6. The benefit maximum was already paid
7. The claim was denied as it was a non-covered benefit
8. Lack of information caused the denial

One of the most frustrating denials and a type of denial usually overlooked, are those that are stated in a policy booklet, but not read by the patient or insured. Individuals, prior to receiving an expensive medical treatment or have a lengthy hospitalization should always read the policy booklet to check first, if the medical procedure/service is a covered benefit, and second, to identify if there are any policy limitations or guidelines that must be followed in order for that service to be paid.

If I can be of assistance to you, or a family member, please send me an email or call my disability law practice at (786) 242-4146.