4 Tricks Your Insurance Company Might Use to Try And Deny Paying Out Your Claim


Insurers and their billing processes are complex and inconvenient for patients and providers alike. While a medical provider may face an unreasonably long wait before they receive payment, a patient will assume that things have been taken care of, only to receive bills months later.

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Unfortunately, insurers have various ways to avoid paying the cost of treatments that are supposed to be covered. These practices are common in America’s health insurance sector, and insurers are increasingly denying claims despite record profits. Here are four ways insurers avoid paying claims, as well as some tips on fighting a denial.

Narrow Networks and Out-Of-Network Care

Narrow-network plans are typically less expensive for consumers, but they often present challenges. In some cases, hospitals and providers are in-network providers, while ancillary providers (such as pathologists and anesthesiologists) are out-of-network. Insurers often delay payment or bring claims against out-of-network providers in the hope that they’ll simply give in. In the event of such a denial, an insurance claims attorney may be able to help you build a recoupment defense.

Denying a Valid Claim

According to the Department of Labor, one in seven insurance claims is at first denied. The reasons are as mundane as improper diagnosis coding, but in some cases, insurers allege that procedures aren’t medically necessary. By double-checking information on claims forms, ensuring proper procedural and diagnostic coding, and requesting pre-authorization, you’re less likely to have a claim denied.

Compliance Crackdowns

Insurers are looking for ways to get out-of-network providers into the fold by auditing them for non-compliance. While compliance checks are important, many medical providers aren’t sure how to stay compliant. Without covering your bases, you’ll give an insurance company another reason to deny your otherwise legitimate claim.

Intentional Confusion

Health insurers commonly rely on customers’ confusion to help them avoid paying claims. Contract language is complex, and though most states have ‘plain English’ consumer contract rules, many are unsure of the risks they face. Confusion not only leads to compliance mistakes as mentioned above, but it may also lead to billing errors. 

Insurers know that healthcare providers are often stuck between writing off collectible debts and fighting expensive battles to appeal denied claims. Follow these billing tips to ensure that you get everything owed to you by the insurance company.

• Submit a completed, clean claim form with the right modifiers and authorization numbers, as an incomplete claim will waste resources and slow down the process.

• Hold the insurance company accountable. When speaking to the insurer, ask for a reference number with each phone call and ask for higher-level workers if necessary. Not every insurance company employee has the ability to help in every situation.

• Consider filing an independent external appeal in the event of a clinical denial for the absence of medical necessity.

• Remember that you can file a complaint with the insurance regulatory board (for non-ERISA health plans) or the US Department of Labor’s Health Bureau (for ERISA health insurance plans).

Be Observant

In the end, health insurers are there to make a profit, and they often do so by denying claims. Physicians, providers, and patients should carefully read their policies and learn as much as they can. By being observant and asking questions, and hiring an attorney when needed, you can protect your rights while getting the medical coverage you’re paying for.

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