Navigating Health Insurance Claims and Appeals
Part 1: The Basic Tools, Chapter 1: The Health Insurance Maze Page 5
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Determining why a claim has been denied frequently involves calling the insurer, the doctor, or the hospital, and reviewing the policy provisions that relate to the claim. In some cases, claims are denied because the insurer requires a particular piece of information or paperwork -- documentation -- before the claim can be processed further.
Once the required documentation has been identified, the consumer needs to contact the doctor, testing center, or hospital to try to obtain the appropriate written material. That may involve asking the hospital or testing center for an itemized bill, or asking the doctor for a letter explaining why a particular treatment or service was medically necessary.
After the material has been obtained, the current system generally requires the consumer to send in a claim appeal, asking the insurer to review the claim once more. The documentation has to be photocopied by the consumer and sent in with the appeal. If the appeal is rejected, the system places the responsibility for filing additional appeals on the consumer, not on the insurer or the doctor.
Although such appeals -- and the paperwork and record keeping that are part of the process -- may eventually result in a successful resolution of claim problems in many cases, a great deal of knowledge, time, and energy are required on the part of the consumer. In addition, the whole process is often enormously frustrating.
However, many experts are convinced that there is no need for the consumer to be directly involved in routine claim-filing and claim-processing at all at this point. In fact, some experts have concluded that the present system could be completely restructured so that it's based on a computerized, electronic approach. Such a system could be set up so that routine claim-processing problems would be resolved between insurers and providers -- doctors, hospitals, and testing centers -- without the need for intervention by consumers. A computerized, electronic system could also completely eliminate the need for consumers to fill out and file claim forms, to photocopy bills, or to maintain detailed records. In addition, the development of a computerized, electronic claim-filing system could speed the entire process and reduce the number of claim errors. It would also be far more efficient, and could save billions of dollars.
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