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What to Do If You Haven’t Gotten Your Health Insurance Reimbursement

Delayed health insurance reimbursement can threaten consumers’ financial security and inhibit their ability to access healthcare.

October 4, 2017 - By Erica Block - read

Insurance companies are notorious for dragging their feet when it comes to processing claims. Whether it’s a prior authorization requirement or a medical coding error, we all have to deal with a delayed insurance claim at some point. After all, it’s not unusual for insurers to say they will not cover a test, procedure, or service that your doctor ordered.

At some point, most of us will have to submit a claim to our health insurance carrier for a treatment or procedure we paid for out-of-pocket. And most of us will wait for months on end to be reimbursed. Health insurance claim delays and denials are not only frustrating–they can threaten policyholders’ financial security and ability to access necessary medical care.

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Unfortunately, having medical coverage also means dealing with inefficient payment systems, increasingly complex and confusing reimbursement requirements, and over-worked, poorly trained health insurer employees. Knowing how to properly contest a claim payment decision is key to maintaining your sanity and your financial health.

Most of us don’t have enough time nor patience to wrangle with an insurer over payment. The guide below includes tips on how to deal with a delayed insurance claim. Here’s how you can navigate the claims process, minimize hassles, and get all the money you’re owed.

What Is an Insurance Claim?

A health insurance claim is a formal request for reimbursement which consumers submit to their health insurance carrier. A health insurance claim form contain the following information:

  • Name of the planholder;
  • Name of the insurance company;
  • Policyholder and group ID number;
  • Whether the injury or illness is work-related;
  • Date of the medical service;
  • Services and/or procedures that were carried out;
  • Corresponding medical codes;
  • Itemized charges for each treatment or procedure

After receiving this formal request for reimbursement from a policyholder, insurance companies review the health insurance claim, check for errors and inconsistencies, and confirm that the medical services listed match the medical and diagnosis codes indicated on the form. Assuming the insurer finds no issue with the policyholder’s claim, the insurance company then goes ahead with a health insurance reimbursement to the policyholder for the amount he or she paid up-front and out-of-pocket for medical care.

Still Waiting for That Check in the Mail?

Unfortunately, health insurance companies are notoriously slow when it comes to processing health insurance claims.

The health insurance claims process is inefficient for a number of reasons:

  1. Health insurance claim forms are confusing and difficult to fill out;
  2. Many insurance companies use outdated accounting practices and many do not devote the resources needed to increase their administrative efficiency;
  3. Perhaps most controversially, insurance companies have a financial interest in holding onto your money for as long as possible.

The problem, though, is that delayed health insurance reimbursement for covered medical services is no longer a run-of-the-mill inconvenience. As the cost of healthcare in the U.S. grows more and more exorbitant, delayed and denied claims have turned into an issue of consumer financial security. And when insurance companies drag their feet in paying up, consumers begin to question why they pay for medical coverage in the first place.

What Causes a Delay in Health Insurance Claims?

Sometimes delay in a health insurance claimis the result of an insurer investigating a claim and deciding that it doesn’t fall within the health plan’s scope of coverage. But in other cases, delays are the result of miscommunication. Because every health care plan has its own internal billing guidelines and coding procedures, information doesn’t always flow swiftly between providers and insurers.

Follow These 5 Steps to Follow Up on Your Delayed Insurance Claim

1. Identify Why Your Claim Was Delayed (or Denied)

Let’s say your claim was sent back to you for additional information, or returned to your healthcare provider. Maybe you overpaid your bill or were charged your monthly premium after canceling your coverage. What can you do and what solutions are available if your retroactive refund takes longer to process than you had hoped it would?

Most delayed claims are not due to malicious intent on the part of the insurer, but rather are the result of a coding mix-up or administrative error. If you submitted a health insurance claim form to your insurer months ago and have yet to hear back or receive payment, your first step is to figure out why there’s a holdup (or, if the insurer rejected your claim, ask why it was denied).

2. Dealing with a Delayed Insurance Claim: Make a Few Phone Calls

Planholders are often frustrated with how long it takes their insurance company to respond to their requests for coverage–and understandably so. A solutions-oriented mindset can go a long way in rectifying the situation. Start with a phone call.

  • Call the Doctor or Hospital: If you’re questioning a hospital charge or a bill from a physician’s office, you may be able to ask the doctor herself about the charge, or you may have to start with someone in charge of billing who can work on it for you. Whatever you do, keep calling until you get the right person on the line.
  • Call Your Insurance Company: If you’re dealing directly with your insurer, call your insurance company to inquire about the status of your health insurance claim. Or, if your claim was denied, call your insurance company as soon as you receive your Summary of Benefits and Coverage to learn why your claim was denied. Be prepared for a long wait on the first call–a customer service representative must collect your information and confirm your identity before resolving the issue at hand. Do your best to be patient and courteous. Health insurance claims representatives handle angry, upset policyholders all day–they are more likely to be helpful to someone who is polite and respectful.

If the customer service representative with whom you speak is uncooperative or unhelpful, ask to speak to his or her supervisor. Persistence will get you everywhere.

3. The Importance of Documentation

If you’re waiting on a delayed insurance claim pay out, it’s important that you take notes of all phone conversations and interactions with the insurance company, including the:

  1. Date and time of the phone call;
  2. Names of the people with whom you spoke; and
  3. A description of what was discussed

In the insurance world, documentation is king. If your insurer’s customer service representative offers to make an adjustment to your bill, ask that they confirm their offer to do so in writing (or via email).

4. If Your Claim Is Denied, File an Appeal

Nobody wants to learn that their request for payment for care they’ve already received, has been denied. But there are steps which consumers can take to maximize their odds of filing a successful health insurance claims appeal appeal and recouping what they spent on care.

If a claim is denied because of incomplete or inaccurate information, a physician may need to clarify or correct the claim submission.  However, if the claim is denied due to insufficient medical necessity or lack of prior authorization, the policyholder’s doctor may need to write a letter to the insurer which explains the policyholder’s diagnosis and articulates why a certain course of treatment was medically necessary.

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5. Stay Organized

The information you need to file an appeal–in addition to your insurance plan details–can be found on your explanation of benefits (EOB). This information includes:

  • Your Claim Number: Each health insurance claim is assigned a unique number so it can be identified in an insurer’s system. Though it may be possible to locate claims without this number, it is much more difficult and time consuming. Make the customer service representative’s job easy–have your number accessible!
  • Healthcare Provider Details: Have the name, address, phone number, and physician license number of the doctor whose claim is in dispute. In some cases, the provider listed may be a company, rather than an individual.
  • Dates of Care / Service: Some medical services are provided over a series of visits, even though they are billed as a single service. Have the exact dates at your avail. It is also helpful to know when the claim was sent to your insurer by the provider.
  • Network Status of the Provider: Your appeal will be much stronger if your physician or is included on your insurer’s list of in-network providers.

How to Appeal Your Insurer’s Decision to Deny Health Insurance Reimbursement

If your insurance company denies your health insurance claim, you have the right to appeal their decision. The appeal process can vary depending on your insurer and their company policy.

Some key aspects to keep in mind:

  1. Learn About Your Specific Insurer’s Appeal Process: Check your plan’s website or call the insurance company’s customer service line to learn about the appeal process. You’ll need detailed instructions on how to file an appeal and how to complete specific forms. Some carriers limit the timeframe of when this process can happen, so remember to ask if there is a deadline for filing an appeal.
  2. Inform Your Doctor & Hospital to Hold Off on Billing: Once you choose to appeal your claim denial, let your doctor or the hospital know and request that they hold off on billing you until you know the status of your claim.
  3. Keep Track of All Paperwork Tied to Your Medical Work: It also helps to have any pertinent documentation, billing statements, and other paperwork in order. Keep records of everything: bills from your healthcare provider, your explanation of benefits, copies of notifications from your insurer, medical records.

If You Have Healthcare Through Obamacare: Internal Appeal

If you bought your health insurance plan through the government marketplace, the process is referred to as an “internal appeal.”

  1. Internal Appeal: In order to file an internal appeal, you’ll need to submit a series of documents to your insurer. For example, you may need to provide a confirmation from your doctor, in writing, specifying the medical necessity of the treatment or medication you received and which your insurance company didn’t cover.If the internal process doesn’t resolve the problem, policyholders can request an external review of their claim within 60 days after their insurer rejects their claim for the second time.
  2. External Review: During an external review, an objective third party will review your claim and your case for appealing the insurer’s decision. If the third party rules in your favor, your insurer is legally obligated to pay your claim. If your claim is rejected after the third-party review, you won’t be able to go through the appeal process again.

Note: For Medicare beneficiaries, there is a separate appeals and review process that you can learn about on Medicare.gov.

Mental Health, Counseling & Addiction Treatment

Appealing claims for mental health or psychiatric care can be particularly arduous. Inpatient treatment often requires pre-certification, if insurance covers this type of care at all.

Twenty-nine percent of patients report that they’ve had a mental health insurance claim denied based on “lack of medical necessity,” compared to 14 percent of patients who say they’ve had purely “medical” claims denied, according to a 2013 survey reported in JAMA Psychiatry.

If you’re appealing a claim for the cost of a stay in an inpatient facility, be sure to address why you (or the patient, if it’s not you) were there for the duration in question. Unfortunately, addiction and mental illness still carry a stigma and insurance companies unjustly make an artificial distinction between physical and mental health.

Delayed Insurance Claim? Follow Up. Then, Follow Up Again.

Follow up with your insurer on a regular basis to check the status of your delayed insurance claim. Be persistent, calm, and explain that you intend to pursue the appeal until it is resolved and the claim is paid.

Many appeals take place over the course of many months, so call your insurer often and take notes of each call.

Enlist the Help of a Patient Advocate

If the thought of filing an appeal overwhelms you and you need a helping hand, you may want to enlist the assistance of a patient advocate. The Patient Advocate Foundation and their guide to the appeals process can direct you to the resources and services you need. The organization can also offer advice when it comes to expediting a delayed insurance claim.

Delayed Insurance Claim? Know Your Rights.

  1. Patients Can’t Be Denied Insurance: Federal rules stipulate that patients cannot be denied insurance — though there is no guarantee that all healthcare services are covered. The Affordable Care Act outlines national standards, enabling people who are denied treatment to appeal that decision to their insurance company and, if necessary, to a third-party reviewer.
  2. Prompt Pay Laws: Many U.S. states have “prompt pay” laws requiring insurance companies to pay health insurance claims within a specified number of days — usually it’s 30. That said, the rules governing a delayed insurance claim often differ in each state.
  3. Insurers Must Not Prioritize Own Financial Interests: The law also specifies that health insurance companies cannot put their own financial interests above that of their policy holders. Some doctors have accused insurance companies of delaying authorization of payment for benefits as a tactic meant to wear a person down to the point where they give up on their claim.

Taking the Next Steps

Whatever the situation, a delayed payment – especially in the form of health insurance reimbursement – can at best be a minor hassle and at worst a financial burden. Make sure you know who to reach out to in these situations.

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