Healthcare providers and health insurance companies don’t always agree on what care should be covered, often leaving the patient stuck in the middle.
Physicians and hospitals want to provide the care believed to be necessary, while the insurer wants to avoid overpayment or paying on an incorrect claim, said Shawn Stack, a policy director for the Healthcare Financial Management Association. Further complicating matters, insurers and providers often communicate through computer software that doesn’t talk well to each other, causing delays and breakdowns in resolving those situations.
“This does come up, believe it or not, quite a bit,” Stack said.
That leaves the patient with no clear path to resolving the matter.
“Unfortunately there’s no magic bullet,” Stack said, but there are some optional steps to try to reduce frustration and move process along.
- Ask the insurer for written documentation about what the claim is being denied or held for, and ask the provider what correction is required. Having that paperwork helps protect the patient from being assigned responsibility over something that they can’t really control.
- Ask the provider’s billing office to contact the insurer to help resolve the issue.
- For denied claims, patients can file an appeal that forces the insurer to respond in writing, which can pressure both sides to act, Stack said.
- Ask the insurer to connect you with a member advocate or case mananger. Their job is to help untangle payer-provider disputes.
- Finally, if you hit a wall, you can file a complaint with your state insurance department regulator, which takes balance billing and improper claim handling seriously.