- If it's denied because the service is supposedly not covered under the patient's policy, and I see that they've had similar services covered previously, I always call the insurance company. Often this straightens things out, and the claim is "reconsidered." This can take up to 6 weeks, believe it or not. If it turns out that whatever it is isn't covered, the patient gets billed.
- If the service is denied because the patient has received the service within a period too short to be covered (ie, a complete physical within 2 years when the policy only covers one every 3 years), we have to bill the patient for the service. It's the patient's responsibility to know what their insurance plan covers.
- Sometimes a claim is denied because the patient is no longer covered by that insurer. I always check this online - almost every insurer has a website where providers can at least check eligibility. If I get the information that the patient's insurance has been terminated before the "date of service," I attempt to call the patient to get their new insurance information. If they don't have any coverage, or they never return my call, we bill the patient for the visit.
- Insurers are very wary about whether an office visit covered a "Pre-existing condition." This refers to a health condition that existed before you started coverage with them. Often we are required to send your medical records to the insurer so they can investigate it further. This can hold up your claim for literally months, and then, it can be denied. We have no choice but to bill you for this visit.
- Sometimes a claim is denied because we made a mistake. Read this article (which prompted this post, by the way) and you'll see some of the coding errors that can happen. In our office, Dr. Nelson and Dr. Hahn code their own office visits in what we call an "encounter". In order for an encounter to be sent as a claim to your insurance company, they translate their visit notes into CPT (Current Procedural Technology) codes describing what they did during the visit that are linked to ICD (International Statistical Classifications of Diseases) codes that indicate what conditions they were treating. If these don't make sense when they're linked on a claim, it's rejected. Sometimes a CPT code hat's not appropriate for a patient might be used by mistake-- maybe they used a CPT for a preventive visit for a 12-17 year old when they were actually seeing an 18-year old. Usually this is a simple mistake on the provider's part. We fix it, send it back, and it's paid. This, too, can take 6 weeks for the insurer to correct.
There are other things that can happen, too. It comes down to this. It's the patient's responsibility to know whether or not they have insurance, and what is covered. When you check in at our office, you are asked "Has your insurance changed? Have you received a new card?" Before coming in to any doctor's office, you should make sure you're covered for what you're going in for, especially if it's a new office, or something you haven't had done before. It's also your responsibility to review the Explanation of Benefits that the insurance company sends you following any visit where you used your insurance. If there's something on there that you don't understand, you can call them and they should explain it to you. And it's our responsibility to send in correct claims, and to follow up with those that don't make it through for whatever reason.
If you get a bill from us that you don't understand, we will always discuss it with you. We keep copies of the Explanation of Benefits that we receive when your claim gets paid, and we can help explain those to you as well if you're having trouble understanding why an insurer didn't cover something. We know how confusing it can all be.