Health Insurance Claims Resolving a Dispute in your Favor can be Simple

Settling an insurance claim dispute can be easier than you think especially if your claim was filed directly by your doctor’s office. The reason for this is that many of the errors that find their way to your insurance claim come from the data that is entered in your file or on the medical billing document at the doctor’s office.

It is disheartening to receive an EOB (Explanation of Claims Benefits) stating that the insurance has not paid on your claim. Please make your first call to the doctor’s office first and ask them to help you understand why your claim was denied. Very often, they can find the mistake quickly if it originated from the data entered.

Insurance policies are becoming more complex and it is difficult to understand exactly what procedures are covered and how often they are covered. Even the doctor’s financial staff has trouble staying on top of all changes.

Many doctors’ offices refile claims for their patients if there is a problem with the insurance payment. Not long ago, I worked in a doctor’s office where an insurance company changed a pay rate that was retroactive to an earlier date. All claims with that insurance company had to be updated and re-filed with the corrected information.

The doctor’s office has both hard and computerized copies of your claim on file. If any part of the claim is incorrect, they’ll be able to compare the EOB document, the billing document and the computerized record. If an error is found, the office will make corrections and re-bill the insurance company.

1. Sometimes the reason is as simple as the fact that your deductible has not been met. Many insurance carriers, including Medicare has a deductible dollar amount that must be met before the insurance starts to pay on your claims.

2. Occasionally a diagnosis code (ICD-9) is changed by the insurance, but the information may not have been posted correctly on your claim. Your doctor’s office will correct it and re-bill your insurance.

3. Claims are denied when the information on the insured is incorrect. This could be a simple error in spelling or a data input error.

The staff at your doctor’s office is familiar with placing calls to insurance companies and resolving the types of questions or errors that cause a rejection of a claim.

If after your own investigation, you have to call your insurance company, you can ask one of the staff at your doctor’s office to help you place the call. Sometimes, depending on the nature of the problem with the claim, an office staff member will make the call for you.

If you have HMO insurance, some problems can’t be resolved in your favor. With HMO insurance, you must see a doctor within your provider network, and you must have a doctor’s referral before the insurance will pay for specialist services. If you haven’t followed the rules, you will have to pay for the services.

By calling the doctor’s office first, you can eliminate any unnecessary delays in your claim process. Start there with your medical claim questions and you probably will avoid a big hassle with your insurance provider.