Navigating healthcare

By Diane L. Marolla, LICSW

Why Every Consumer Should Care About The Medical Claims Payment Process

My career in the managed care industry (or as most consumers know it, the health insurance industry) was by accident. I began working in the industry in 2002 after I became a Clinical Social Worker. I remained employed by the health insurance industry up until 2017. Simply stated, I certainly learned the good, the bad, and the ugly about how the industry works. I am grateful for all my experiences as my knowledge now allows me to help healthcare facilities, practitioners, and consumers understand that there are absolutely no guarantees that an office visit, a prescription, or a procedure will be covered and paid for by health insurance. Getting a medical, dental, or behavioral health claim paid is a complicated process of billing and coding. At the end of the day, if a claim does not get paid, guess who gets stuck with the bill…… This is why unpaid medical bills remain the number one reason why Americans are filing for bankruptcy.

Since leaving the health insurance industry, I have been knee deep in helping resolve claims issues for primarily non-profit healthcare entities, and small healthcare practices in Rhode Island. What I have witnessed is hundreds of thousands of medical, dental, and behavioral health claims being rejected for payment for a garden variety of reasons. Ultimately, if a healthcare facility or a doctor’s office can’t get a claim paid for by a health insurance company, they have to bill a patient for the services. If that bill goes unpaid by a patient, it then goes to a collection agency. If they are unable to collect the money from either the health insurance company or the patient, the charge has to be written off as bad debt. We all pay for this broken system.

Because I have been so close to claims payment issues over the past two years, I wanted to research the facts about this topic. According to “up to 80% of hospital bills have errors.” Why should you, as a consumer care about this? Because, if you don’t pay attention to bills you are either receiving from a hospital or your doctor, they could contain errors.

Other reasons that your health insurance company may be denying a medical, dental, or behavioral health claim could also be for the following reasons:

Insurance companies have what is called “timely filing” requirements. That means, your health care provider has to submit a claim within so many days of when the service is rendered. The typical time frame is 90 days from the date of services. It can be, however, less.
The service rendered to you may not be a covered service. You always need to check your policy to ensure it is a covered service. In addition to that, I always encourage consumers to call their insurance company and ask them. If you do, be sure to document the date and time that you called and who you spoke with. All insurance companies record calls, so should they deny a claim, you can appeal the decision stating that you spoke with a representative who said the service would be covered.
Many services require an authorization from the insurance company. This means that either you or your health care provider have to contact them to get the service approved by them. If you think, however, that even if an authorization is obtained that the health insurance company has to pay, you are wrong. An authorization never ensures payment of a claim. They still can deny the claim.
Many services have to meet what is called “medical necessity” requirements. This means, that the insurance companies have certain criteria they use that says you truly need the service or the procedure. If you think your doctor actually makes that decision, think again, because they do not.
The health care provider or facility may not have a contract with your health insurance company. This is something you should always check ahead of time before a service is rendered to you.
Your health insurance erroneously denies payment for the claim.

Even if a health insurance company pays in full, it still is not a guarantee for you. Why? Because health insurance companies do what is called “recoupments” which mean they actually will take back money that they paid to a healthcare provider. They can do this for a multitude of reasons. Recently, with one of my clients, I saw a claim that was paid to them recouped from a service they rendered four years ago. The claim had to be challenged by the healthcare provider, only to learn that the health insurance company took back the claim in error. The provider had to dedicate time and resources to prove that the money was taken back in error.

When I do get phone calls or emails from consumers about claims that deny, I always tell them that they should challenge it. First, call your healthcare provider and find out why. Make sure it was not a billing error on their end. After you call them, call your insurance company. Be sure to use the appeal process through your health insurance company to challenge the claim that wasn’t paid. Also, utilize the services of the RI Healthcare Commissioner’s office. They have staff that will assist you with challenging your health insurance company.