SMART Tips on Reversing a Denied Health Insurance Claim

by Dr. Linda Burke-Galloway

stamped deniedI've had more than my share of frustrations in the past when I've had to battle insurance companies about needed services for my patients that were either denied or "not covered." My daily intake of blood pressure pills is a constant reminder of the stress that accompanies my job.

However, I have recently looked at insurance companies through a different set of lens and I was a little surprised at the view. Sometimes the denials are not the result of stonewalling, but on the incompetency of a provider's billing clerk.

I had a $600.00 dental bill for services that was denied by the insurance company. Because I took the denial on face value, without further investigation, I made payment arrangements, assuming that the services were not covered. I was wrong.

While researching my son's services, I discovered that my dental services had been erroneously denied because

(a) the dentist's office erroneously billed for my upper teeth rather than the lower teeth and
(b) they failed to submit information regarding my recent extraction that would validate the procedure.

The same thing happened when my sons' pediatric services were denied. I contacted the insurance company directly and discovered that their pediatrician's office had used the wrong billing code thereby giving me a liability of $814.37. Both billing errors could have cost me $1400.00.

The lesson learned was that insurance companies will pay for services if you follow their rules of engagement.

S -- Seek answers. Never accept a denied insurance claim based upon its face value.

M -– Monitor the "procedure" codes used on your billing statement in your provider's office.

A -- Assume someone made a billing error when you receive an insurance denial.

R -- Respond to denied claims immediately. Don't let them sit on your kitchen countertop unattended.

T -- Talk to your provider's billing department as soon as you discover your denial was based on their error.

An insurance denial is not written in stone. Most insurance companies are quite willing to pay the claim, once the error has been corrected. Following these steps might save you significant aggravation and money in the future, not to mention the disappearance of an uninvited headache.

Linda Burke-Galloway, M.D., descended from two 19th-century midwives, is a board-certified ob-gyn and author of The Smart Mother's Guide to a Better Pregnancy: How to Minimize Risks, Avoid Complications, and Have a Healthy Baby. Dr. Burke-Galloway graduated from Boston University School of Medicine in 1987. She did her ob-gyn residency training at Harlem Hospital, a Columbia University teaching hospital.

Dr. Burke-Galloway's passion for babies inspired her to provide quality healthcare to medically underserved women, many of whom had high-risk problems. She is an expert in recognizing and managing obstetrical risks before they spin out of control and has prevented potential disasters for both mothers and their unborn babies. Dr. Burke-Galloway is also a medical malpractice consultant for the federal government.

Read more from Dr. Burke-Galloway at her blog.

Copyright © Linda Burke-Galloway. Permission to republish granted to Pregnancy.org, LLC.