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Expert Elder Care Guidance
Expert Elder Care Guidance
My father received a private insurance claim denial for a procedure that he really needed. He can’t pay the $13,000. What do we do?
The Government Accounting Office, the nonpartisan congressional agency investigating how the federal government performs and spends taxpayer dollars, would recommend you appeal – and do so quickly. Often, people believe they just don’t stand a chance when fighting large insurance companies; they see themselves as David taking on Goliath. But David did win, and it turns out consumers can, too. The GAO found in a recent study on private health insurance and coverage denials that 39-59 percent of consumers who contest insurance claims win their appeals.
A recent national study by an insurance trade association found a similar pattern: 40 percent of insurance claim denials were reversed on appeal.
Why is this? No, insurance companies are not softening up. The majority of reversals are because of billing errors made during the original claim, often caused by duplicate claims or missing information. One in five reversals is because the original medical claim was processed inaccurately by the insurer. Based on these facts, most of the time all that’s required is a phone call to the insurer to clarify the claim, and you can forgo the insurance appeal letter. That’s easier said than done, but the potential result is worth playing the “menu prompt game” and listening to elevator music while you’re on hold.
If the phonecall fails and you must appeal the decision – or if you lose an appeal – you should take the following steps:
Even if you lose the appeal and must pay the bill, always try to negotiate a more reasonable price. The amount you’re being asked to pay might be significantly higher than what other third parties pay.
Most of us know not to pay the “sticker price” for a car. Instead, a smart shopper heads for the Kelly Blue Book to find out the fair asking price for a car based on its year, model, make and condition. You can do the same regarding medical services by going to healthcarebluebook.com. The Healthcare Blue Book is a free consumer guide to help you determine the fair prices in your area for a range of health care services. Use this information to make a reasonable offer to the billing department as to what you’ll pay, and determine a period of time that’s realistic for you.
Another resource is the Patient Advocate Foundation, which assists consumers with arbitration, mediation and negotiation to settle issues related to access to care, medical debt and job retention related to their illness. Visit them at patientadvocate.org or call 1.800.532.5274.
Consumers are not alone in being overwhelmed by the hassles in dealing with insurance claim denial. So are physicians: A study that appeared recently in the journal Health Affairs reports that U.S. doctors are spending more than $82,000 each year per physician interacting with insurance companies and health plans regarding claims, coverage and eligibility issues, denials and billing questions. It adds up to more than $31 billion per year.
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