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Know Why Your Insurance Won’t Pay Certain Claims

Most of the time, medical exigencies are unexpected and can cause a financial upheaval that is usually frustrating and overwhelming. While you can’t avoid some medical conditions, you can be on the safer side by buying a health insurance policy that covers different services. However, you need to understand certain aspects of your insurance company, such as its coverage, how much it pays for a particular service, and how much you need to cater for. 

Unfortunately, sometimes an insurance company may fail to pay specific claims due to problems on your side or theirs. The good news is you don’t have to accept their refusal to cover your medical claim because there are specific measures you can take to reverse your situation. They include:

Consult a medical billing professional

Misunderstandings between your healthcare provider and the insurance company may result in you having the entire burden of the bill. A common one referred to as bundling occurs when your specialist bills separately, a primary and secondary procedure.

For example, the two processes can be billed independently if a surgeon performs an incision before a surgical procedure. However, your insurance company merges the two and pays out as one claim. In such cases, your insurance company may fail to cover the second procedure. Kemberton complex coverage takes care of such sophisticated insurance issues.

Follow up with your insurance company

The complex nature of medical billing makes it prone to error. Many errors can arise from your insurance company, such as misinformation about coverage of a particular service. Sometimes the problem results from processing your claim, or it could be that your healthcare provider swapped your billing with that of another patient.

For example, your visit to a doctor for screening could be categorized as a consultation with a gynecologist. Sometimes your information can get lost during processing, or your provider leaves out additional information the insurance company needs.

Such errors can be the reason why your insurance company won’t pay particular claims. While this may seem like the company’s problem, the responsibility is on you to make sure all the needed information is submitted and processed.

Appeal through your company’s official press

Medical plans work on different terms, with some requiring referrals for patients to see a specialist. Your insurance company could deny your claims if you had a session with a specialist without a referral from your doctor. To avoid extra medical bills, ensure to get a referral for such incidents in the future.

Some companies may reimburse after a client receives a pre-approval. However, if you are still stuck with the bill, you can appeal through your insurance company’s official press. Since most plans cover medically necessary services, your insurer may deny claims that don’t fall under the medical category. In such cases, you can ask your doctor to hand in a form to your insurance company stating that the service offered was medical.

Negotiate with the company and health providers

If you are still stuck with a medical bill after trying out other tactics, you can talk with your insurance company to let you slowly pay the medical bill with zero interest. You can also ask for a discount or reduction in the amount if you offer to settle the account immediately. 

Think of other solutions to help you clear your outstanding balances to avoid your debt being sent to debt collectors. Research to help you understand the estimates of different treatments in your state or location to help you negotiate.

Talk to a medical billing advocate

Some insurance companies do not adhere to their policies, causing conflicting results to what their guidelines state. Because noticing such information can be challenging, consider working with a medical billing advocate who can help you look out for unfair billing practices.

Most of the medical bills have errors that companies are responsible for. Your insurer can forgo the bill or reduce your costs after negotiations with a medical billing advocate.

However, you choose to address this, ensure you are persistent yet polite in your efforts. Keep records of the dates and names of each person you speak with and avoid procrastination. Delay may cause your bill to land in the hands of debt collectors, making it harder to negotiate.



  • Icy Health Editorial Team

    The Icy Health team curates the most interesting content and healthstyle related articles for our readers. Our content is vetted by doctors, medical professionals, and established writers.

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