Deny, Deny, Deny

This is one word no one wants to hear when they need to submit a health insurance claim.

It’s a tough call, they say, to deny a health care claim. One wonders when such things like insurers retroactively cancel insurance policies after people get sick. While shocking, it is far more common than one cares to admit. In fact, an estimated 10 to 15 percent of health insurance claims are denied for reasons ranging from missing deadlines to not admitting to a pre-existing condition.

The most difficult of all the denials is when an insurance company deems a treatment unnecessary or the results not proven. This leaves the insured between a rock and a hard place.

The foundation of this problem is that insurance contracts legally grant those insurance companies the right to manage a patient’s care. This right includes denying coverage without even seeing the insured. It also means the insurance company usually has the final say, that is unless the state wades into the fray.

The problem with the area of insurance carrier denials is that many of the refusals to honor claims seem to be arbitrary. One company may agree to cover and the next will decline. Drugs might be given the nod in some instances, but not in others. There’s no manual that says what will be covered and what will not. The patient finds out as they go through the system.

No matter what the reasons for denials, if a patient is faced with a “No” then they are stuck with the expenses. The question then becomes if the insurance companies are not willfully passing along expenses they should be paying to the insured. This situation can be an enormous shock to the patient if the procedure or test comes with a high price tag.

This situation isn’t getting any easier either. In fact, it has all the earmarks of getting worse. Witness the introduction of “denial engines,” geared to reduce reimbursements by 3 to 10 percent. These sophisticated data mining programs with names such as Ingenix Detection Software and Bloodhound Technologies’ ClaimsGuard, cull records for indications that claims may be outside the insurance company guidelines. What this boils down to is just one more excuse to deny legitimate claims.

It cannot be emphasized enough – know the details of the insurance coverage in any package being contemplated. Knowing right up front what is and is not covered is at least a start to understanding and staying on the right side of the claims form.

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