Don't Accept Your Insurance Claim Rejections

A young girl sits in an insurance office. She was a receptionist for a year, then recently took a medical billing course. She applied for a job in the insurance claims department, in primary claims submissions. She is so happy to have this new job, and has already planned how her lifestyle can improve with her small but significant raise in pay.

A company CEO at the same firm sits in his office, pulling up the latest plan for next month. Claims rejections need to increase to meet his bottom line. During his weekly meeting with staff, he stresses the importance of paying attention to every facet of claims submissions, checking to make sure every line is filled in accurately and every box is checked correctly. Costs are going up again, he states, and we cannot afford to pay claims that are not eligible.

The word filters down the line to the claims girl. Make sure the claims you process are completely correct. We need to approve only 62 percent of claims this month, and 59 percent next month. Too many claims are getting through and our approval rate is too high.

The words are implied, and the message received, loud and clear. Money is on the line, from the CEO's performance bonus to the claims girl's rent payment. She is new to this department, but the person next to her gives her the word "you are approving too many claims. Check your numbers at the end of the day and make sure you only approve 2 out of every 5 you process. The person across from him shakes his head vigorously" start rejecting more claims.

The top claim on this girl's desk is your last office appointment. What happens to it? What do you think will happen?

Fiction? You wish it were. But it is a fact of life. Every claim is handled by so many people that there are so many ways to make a mistake. Or opportunities for error.

Your appointment is entered in the computer. When you come in, the nurse has to fill out a form with the reason for the visit, any connected illnesses or history, and complete information of where and when it started, or happened, if it was an injury. The doctor comes in and examines you, sometimes referring you to a specialist or for tests. He makes a diagnosis and records contributing factors.

Then this folder goes to the coder, who indicates the correct codes for the diagnosis and contributing factors, each with the correct numbers/letters that are current and cohesive with each other. Then the biller, who has to fill in all your personal information, and your current insurance information. She submits the claim to an insurance clearinghouse that reviews this claim and either rejects it or sends it to the correct insurance company. The insurance company receives the claim and forwards it to the correct claims office. The claims girl gets the claim and checks it for accuracy, form, procedure and coverage. And if she isn't worried about her performance numbers, or hasn't had an argument with her boyfriend today, or doesn't have a bad sore throat, or a window by a pretty park, you might get your claim approved.

This may be a slight exaggeration, but don't count on it. And yes, lots of company have lots of inherent errors, but I'm not picking on the insurance companies or medical offices. I'm trying to save you healthcare dollars.

So when you get your claim rejection, it may be caused by any of the inconsistencies or reasons possible, but you probably won't know. Call your insurance provider and go over the claim with a processor. If it isn't approved, ask why not. Check with your doctor's office to see if all the information is correct and the person working in that department has been on the job long enough to know if it is. Then submit an appeal, and maybe another appeal after that.

I can tell you that the squeaky wheel gets the attention. So when is comes to insurance claims, squeak LOUD and squeak OFTEN. Your wallet will thank you.