Overturning Insurance Denials

In addition to state and federal laws, health insurance plans are also governed by a complex set of contractual relationships.  If an insured or service provider fails to comply with the rules established by these contracts, their claim will likely be denied.

Our investigators have the time to decipher the reason behind a denial, and once they have discovered the problem, our investigators will work with the patient and service provider to correct the problem that resulted in a denial of payment.

I)  Lack of Coordination of Benefits-When an individual possesses more than one insurance plan, it is necessary for that individual to file a Coordination of Benefits ("COB") with each insurer.  Frequently, claims are denied because an insured has not filed or updated his/her COB.

Once one of our investigators has identified a COB issue, they will bring this problem to insured's attention and will assist that person with updating their COB.

II)  Improper Billing- Too many claims are denied because of mistakes contained within the UB92 or UBO4.  Some claims are denied due to inadvertent typos or inconsistent entries on the UB92 or UB04.  Other claims are denied because the enumerated treatment codes (e.g. ICD-9, CPT®, HCPCS) do not cleanly fall into a covered procedure for that specific insurer.

Our staff is skilled at reading medical records and we will confer with your hospital's coding/HIM department to determine if the medical records supports a change in coding that would enable the claim to reprocessed.

III)  Medical Necessity Denials- Most insurance plans contain provisions that the plan will only cover "medically necessary procedures."  Determinations of medical necessity are fact-specific inquiries that will vary from individual to individual.

Any denial due to lack of medical necessity will require a written appeal.  MedClaims has developed strong reputation for overturning denials on appeal by incorporating arguments from our on-site medical consultants.  Our staff has substantial experience writing appeals and knows how to present arguments in a manner that will ensure the highest degree of success.

IV)  Extension of Benefits- Some, but not all, health insurance plans contain extension of benefit provisions, which mandate that a patient cannot be dropped from coverage while he or she is receiving intensive inpatient treatment.  Unfortunately, extension of benefits clauses are frequently not enforced unless brought to an insurer's attention.

For cases that may involve an extension of benefits issue, our staff will obtain copies of the written heath care plan, and if an extension of benefits clause exists, we will aggressively advocate on behalf of the patient for its enforcement.