Fighting to get a health claim reimbursed

Nobody wants to get into a fight with a health insurer, but it may be worth your while. A recent Government Accountability Office report found that more claims problems stemmed from annoying but often straightforward billing and eligibility issues than from disagreements over whether care was medically appropriate. What’s more, the odds are about 50/50 that if you appeal an insurer’s decision, you’ll win.

When Natasha Friedus’s son, Nofi, was born almost two years ago, her insurer refused to pay $1,500 of Friedus’s $7,500 hospital bill because she hadn’t gotten prior authorization for the hospital stay near her home in Seattle. The plan also sent a $600 bill to Nofi, because he’d neglected to inform the insurer that he’d be in the hospital for a few days. “Apparently he was supposed to call before being born,” Friedus says.

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The new mother spent hours on the phone trying to sort out the problem, but she got nowhere. Finally, someone suggested appealing the decision to the insurer and asking for retroactive approval for her hospital stay. That did the trick, says Friedus, even though the insurer had never informed her that she could appeal the bills.

Under the 2010 health law, the situation should improve. Health plans will be required to inform members that they can appeal disputed claims internally within the health plan as well as to an independent review organization not affiliated with the health plan. The new rules become effective in July.

Coding is everything

As anyone who has tried to decipher a health plan’s “Explanation of Benefits” knows, coding is everything. That’s where many errors occur, experts agree. If the CPT (Current Procedural Terminology) code that describes the medical service or test you received doesn’t correspond to the International Statistical Classifications of Diseases code that describes your diagnosis, your claim may well be denied, a decision that will probably be communicated via a “reason code” on your EOB.

Medical services aren’t the only thing that must be in sync with the diagnosis: “The CPT code needs to correlate with age and sex and place of service as well,” says Candice Butcher, head of Medical Billing Advocates of America, which helps consumers resolve medical billing problems. In other words, if the CPT code is for a routine physical for an adult, but the patient is a 10-year-old child, the claim will be denied, says Butcher.

Sometimes claims that appear to be denied because the treatment isn’t appropriate — a particular service isn’t considered “medically necessary,” for example, or is deemed “experimental or investigational” — are actually coding errors, say experts, because the diagnosis code is wrong, for example.

You can’t prevent providers from miscoding your care or insurers from misinterpreting your plan or eligibility, but you can ask your doctor or insurer to cross-reference the treatment with the diagnosis and make sure the two are in sync, says Nancy Davenport-Ennis, chief executive of the Patient Advocate Foundation, which works to resolve these and other problems with health insurance claims.