What Is The Icd-9-Cm Code For Copd With Emphysema Do Your Homework to Minimize Denied Health Claims

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Do Your Homework to Minimize Denied Health Claims

Due to continuous non-payment, the patient’s balance was reversed. The patient disputed that he owed the balance. The service provider resubmitted the bill to the insurance company and was still denied. The following data from the patient’s care plan led to the rejection:

  • You needed pre-authorization based on the submitted codes/modifiers before starting the service.

  • The provided service was classified as non-emergency care based on the tabular documentation, which led to a prior authorization requirement.

  • The provider did not contract with the insurance provider, meaning they did not have to accept the full allowable fee as payment and could bill the patient for the entire uncovered balance over $1,500.00.

As you can imagine, the patient was extremely upset. He said it was an emergency and he was in a lot of pain. If you had known all of the above, you would have chosen an alternative service. He also felt that the service provider should have told him all of this because it was their responsibility. You paid a lot of money to the insurance company only to receive this unfair treatment.

Six areas patients need to know

No matter what type of health coverage it is, you must agree to know the details of the plan’s coverage, and it is your responsibility. Otherwise, you may end up in a situation similar to the one above. If you are unsure of coverage or wording, ask for details. Also, keep in mind that insurance companies can deny premiums by mistake. If you do not agree with the health insurance decision, you have the right to appeal. Be sure to follow the insurance plans’ appeals process to get a timely response.

Six areas should be checked before medical care:

  • Payment points such as deductibles, coinsurance, deductibles, and the percentage of coverage after deductibles are met. There is a huge difference between what in-network and out-of-network providers owe. Patients who get new insurance usually don’t know the difference.

  • Where to find health plan information.

  • Member Resources.

  • How to stay in the network.

  • Out-of-network payments.

  • Preventive services.

Where can you find this information?

  • Websites: All health plans tend to have very extensive websites that are increasingly sophisticated. For example, the United Healthcare website includes a list of prices, providers by zip code, and even whether the provider is accepting new patients. Some of the information is a little out of date, but that’s just the beginning.

  • Documentation: Usually by the beginning of the year, health plans post changes to the following year’s insurance. You can easily find deductibles, co-pays and other information through these documents.

  • Telephone: Call the number on your health card. Make sure you have the reference (tracking) number for the call.

Because you bear more of the burden of your health care costs, knowing this information is imperative so you know the difference between a preventable patient balance and an actual balance—before the bill arrives.

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