Medical insurers can be persuaded to follow through with payment

Health care is not cheap, and many Californians rely on health insurance to help meet the costs. However, getting insurance companies to pay the bills can sometimes be problematic.

Payment problems

The country's Government Accountability Office reported recently that most disagreements between insurers and patients were due to eligibility and billing issues rather than to any dispute over whether a medical procedure was the right treatment.

The Affordable Care Act requires a health care plan to notify the patient in writing when it denies a claim, explaining why it denied the claim. Notification must be provided within 30 days if the medical treatment has already been provided. When treatment requires pre-authorization, the plan has 15 days to explain a denial, and in urgent care cases, the plan has just 72 hours to respond.

Appealing

Patients have the right to appeal any denial of coverage, within 180 days after receiving the notice of denial. They can file an appeal internally to the insurance company by submitting the forms the company supplies or simply writing a letter that includes the patient's name, insurance identification number and claim number, stating that the patient wants to appeal.

If an internal appeal fails, the patient can move on to ask for an external review of the process. An impartial third party expert conducts the external review under standards for consumer protection implemented in the Affordable Care Act. The expert cannot be an employee of the patient's insurer or have any relationship with the insurer. Some states administer external reviews, while federally administered external reviews are the rule in other states.

Insurers are bound by law to abide by the decision of an external reviewer. They must pay claims promptly if the reviewer decides that they should.

Getting results

Many families in California and around the country have struggled with getting health insurers to pay their claims. In one case, according to an article in the Los Angeles Times, an insurer refused to pay for all of a hospital maternity stay because the mother had not asked for prior authorization. The insurer even sent a bill addressed to the mother's newborn, stating that he had not notified the insurer that he was going to be hospitalized. After fruitless hours on the telephone, the new mother finally got results when she filed an appeal. The insurer had never informed her that she could appeal, but someone else suggested it.

In some cases, the problem boils down to errors made when medical personnel enter diagnostic and treatment codes in patient records. If the description of medical services doesn't correspond to the service referenced by the code, benefits could be denied.

It is all too easy to enter wrong codes. For example, the code for an adult's physical examination is different from that for a child. If the patient is a child, but the code is for an adult, for the same service, the claim is likely to be denied.

To navigate the confusing tangle that can result when medical claims are denied, many people rely on a California attorney who has experience dealing with insurance companies. Knowing how and what to communicate to an insurance company can make a big difference in how quickly a denied medical claim can be resolved.