If you have health insurance, at some point you may receive a bill for something that you thought would be covered. A 2017 study from the Doctor-Patients’ Rights Project found that 24 per cent of people with chronic illnesses (including diabetes) had a claim denied by their insurance company. But among those who appealed the decision, the denial was overturned nearly half the time.
Often people assume the insurance company made a mistake and will fix it, but without an appeal that does not happen. “In case of denial, one can re-apply but chances are that once the claim is denied, it will be denied again. In such a scenario, customers can file a case against the company if they are not satisfied with the reasons given by the insurance company,” says Rikita Kharkwal, Senior Associate, Corporate Business Group, PolicyBazaar.com on appealing against the denial of the claim.
PREVENTION IS THE BEST MEDICINE
There are a few points that one should take note of while applying for the claim or before buying the policy.
Divya Nigam, Regional Head, Institutional Business, Religare Health Insurance Co. Ltd., suggests, “Before applying for the claim, the individual should first get the claim registered or ask the TPA desk of the hospital to register the claim. At the time of submission of reimbursement claim do attach all the original documents with discharge summary; hospital reports; original paying slip especially credit card slip to get the claim processed on time. Before buying the policy do read the terms and conditions of the policy as soon as you receive the documents.” With his experience he explains, that sometimes people fight for claims of things which are not covered in the policy, thus there is no point arguing over.
Several times the appeals are turned down with a mere reason that the claims are not covered in your policy terms. Another simple yet important reason is the incorrect processing of the claim.
“Inaccurate information provided on proposal form during application for insurance, any previous health issue/ disease kept hidden from insurance company while issuance of the policy, applying for claim outside the coverage chosen in the policy are some of the factors which make it hard to determine if your claim has been processed correctly,” explains Rikita.
In such cases, you will need to call the insurance company and ask a representative to explain it to you. Before you do, make sure you have an itemised bill from your provider. Also, check if you saw multiple doctors in one visit? Check that each is listed with separate procedure codes. As, if the insurance company sees the same code listed twice for one doctor, they will not consider it.
FILING AN APPEAL
If calls don’t get you anywhere, it is time to appeal. Your EOB (Explanation of Benefits) Team will include instructions on filing and timing, so consult them first. But before you start the process, check with your provider’s office, they are equally entitled to appeal and because they know the process better, they stand a better chance of winning.
If the denial is for a medical reason (rather than because the treatment is simply not covered), your doctor can request a peer-to-peer review. The EOB can talk on the phone with a doctor at the insurance company and explain your treatment plan. If your provider’s appeals do not succeed, find out what reason the insurance company gave, then prove it wrong when building your own case.
Most claims that are denied for medical reasons will have three levels of appeal, two with the insurance company and then an external review, conducted by an independent party. You will need to provide more information with each round, to counter the reason for each denial. After your appeals have been exhausted, don’t give up. Ask for an external review.