California Health Care Providers Can Dispute Denied Insurance Claims

October 10, 2012

California Health Care Providers Can Dispute Denied Insurance Claims

The American health care system is rife with complications. Though health care providers rightly want to focus on helping their patients get healthy and stay well, they also need to get paid for their work. Unfortunately, health care providers too often find themselves fighting with insurance companies to get appropriate reimbursement for the medical treatment they have provided.

When an insurance company wrongly denies a claim, a health care provider has a right to appeal the denial and take legal action against the insurer. A California health insurance attorney can help in this quest. However, before taking action against an insurance provider, it is important to understand some basics about the California health insurance claim process.

Why Are Health Insurance Claims Denied?

After treatment is provided, the health care provider will submit a claim to the insurance company. This is the first place were errors could arise -- if there is a delay in the hospital's or doctor office's workflow or an employee makes an error in paperwork or coding, payment could be delayed or even denied. It is also important to remember that many health insurance companies prescribe a fixed timeframe -- usually 90 days -- within which claims must be submitted.

After the claim is submitted, the health insurance company will review the submission and determine whether to reimburse the claim. According to a study by the American Medical Association, as many as 20 percent of all claims are processed incorrectly, which could lead to insufficient payments or wrongful insurance denials. In some cases, the insurance company's own errors cause the time period for reimbursement to expire, after which the company ironically denies the claim for untimeliness.

If the insurance company decides to deny the claim, it must notify the health care provider and explain the reasons for denial. In addition to the reasons previously discussed, other common justifications for denying claims include:
-Missing or inaccurate codes
-Lack of proper referral for specialist care
-Patient ineligibility for care
-Failure to obtain preauthorization for services rendered
-Providing multiple services in one day

Disputing a Denied Health Insurance Claim

Many denied claims can be resolved by contacting the insurance company and explaining the error. If the company continues to refuse to pay, the health care provider can take more formal action.

Nearly all insurance companies have internal dispute resolution processes that allow health care providers to appeal denied claims. If that process fails to produce the desired result, the health care provider can file a complaint with the California Department of Insurance. The Department of Insurance will review the evidence in the case and determine what obligation, if any, the health insurance company has to pay the claim.

Disputing a health insurance denial requires strict adherence to procedure and deadlines. In addition, success is often incumbent upon presenting accurate and compelling evidence and being able to combat the insurance company's interpretation of the issue. As such, a medical provider can benefit greatly from consulting with a California health care attorney who can help it navigate the complex dispute resolution process.

Article provided by Law Offices of Stephenson Acquisto & Colman
Visit us at www.sacfirminsurancebadfaith.com/