We obtain many questions on our medical claims forum from people who have gotten a rejection on a medical insurance claim and don't recognize the denial and don't know how to handle it. I sometimes believe that we have seen every probable form of denial and then "SURPRISE" - we get a new one. Many times the answer is simple. EOBs are all dissimilar and many are difficult to read. I don't know how many times I have had a worker ask why medical claims were denied only to see that it was not denied at all. It was paid to the deductible.
Sometimes the deductible column is not understandable and you require studying the EOB to find it. It is not extraordinary at all to get a denial that is just completely wrong. I had two today that were paid to the deductible from a plan that usually only has a deductible when the health care provider is out of network. This particular doctor was in network with this health insurance company so it just didn't sound right. I could have just billed the patient but I favor to get this fixed correctly right now if it is incorrect. I called on the two claims and found that one had a $1000 deductible in network which is very curious for this company and the other was paid to the deductible in error and was going to be reprocessed.
Without the phone call to the insurance company I would have sent out two patient details and a few days later on would get a call from one patient saying they didn't have a deductible and we would have made the call to the health insurance claims company then. My point is that many times we get denials that are incorrect or at the very least not understood. What you need to do when you get one of these claims denials is to call customer service at the insurance company and keep asking questions until you understand why it was denied and what you need to do to get payment for that claim. It may have been denied incorrectly and will be reprocessed. It may have been denied for a good reason and the patient must be billed. In order to receive payment, you must get to the bottom of the problem to know what to do next.
Sometimes the deductible column is not understandable and you require studying the EOB to find it. It is not extraordinary at all to get a denial that is just completely wrong. I had two today that were paid to the deductible from a plan that usually only has a deductible when the health care provider is out of network. This particular doctor was in network with this health insurance company so it just didn't sound right. I could have just billed the patient but I favor to get this fixed correctly right now if it is incorrect. I called on the two claims and found that one had a $1000 deductible in network which is very curious for this company and the other was paid to the deductible in error and was going to be reprocessed.
Without the phone call to the insurance company I would have sent out two patient details and a few days later on would get a call from one patient saying they didn't have a deductible and we would have made the call to the health insurance claims company then. My point is that many times we get denials that are incorrect or at the very least not understood. What you need to do when you get one of these claims denials is to call customer service at the insurance company and keep asking questions until you understand why it was denied and what you need to do to get payment for that claim. It may have been denied incorrectly and will be reprocessed. It may have been denied for a good reason and the patient must be billed. In order to receive payment, you must get to the bottom of the problem to know what to do next.