| These days a patient must be vigilant about his or | | | | of the conversation. Keep detailed notes on exactly |
| her own health care in terms of researching | | | | what happens every step of the way, and retain all |
| treatment, securing pre-authorizations, and knowing | | | | related paperwork, even if you're unsure whether it's |
| what to do if their group or private health insurance | | | | relevant. Include in your notes: |
| policy denies a claim. After all, a health insurance claim | | | | * When the required treatment pre-authorization was |
| denial is the last thing you want to have to worry | | | | requested, and received, and from whom |
| about in the middle of a health crisis. A denied claim | | | | * Date of the treatment |
| feels like a knife in the back placed there by the | | | | * What was discussed with the doctor, what actions |
| very company that's supposed to be watching your | | | | were taken, and what follow-up will be required |
| back. Luckily, some claim denials can be easily | | | | Unfortunately, mistakes are common in claims |
| avoided. | | | | processing. Consider a 2002 study by America's |
| According to one lawyer at the Texas State | | | | Health Insurance Plans, which reported that 14 |
| Department of Insurance, "The most common basis | | | | percent of claims submitted to insurance providers |
| for a claim denial in the health insurance industry is | | | | are denied. The same survey found that one out of |
| that the procedure, preparation, or pharmaceutical is | | | | every seven claims had to be re-submitted and |
| not covered by the policy. So, the easiest and most | | | | re-processed due to errors in the original claims, a |
| important way to avoid a claim denial is to read | | | | costly process for everyone involved. |
| through the most recent and most inclusive version | | | | Other things that you might consider include: |
| of your health insurance policy and get a picture of | | | | * Research your state's laws regarding what should |
| the kinds of things that are covered, and those that | | | | be covered in a claim, and what the law considers |
| aren't." This is a great starting point. Make sure your | | | | "arbitrary." This would influence an insurance |
| policy is the most up-to-date. In the past few years | | | | company's definition of "medical necessity" and billable |
| most policies have changed to put more financial | | | | needs. |
| burden on patients covered. | | | | * Make sure your insurance provider and doctor's |
| It's also a good idea to contact your health insurance | | | | office have been in contact with each other, and |
| provider and ask to talk to someone who specializes | | | | that all the necessary paperwork has been |
| in the area of treatment you're receiving. After all, he | | | | forwarded from one to the other. |
| or she might be the very person reviewing your | | | | * If your coverage is fully or partially paid by your |
| claim, so feel free to ask specific questions about | | | | company, make sure you keep your human |
| what might or might not be covered under your | | | | resources department fully informed of the situation |
| particular policy. For future reference, write down his | | | | so that they can help with any paperwork that might |
| or her name and telephone number at the beginning | | | | come up that you can't manage. |