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5 mistakes that lead to health insurance claim denials Posted: October 4th, 2011

By Barbara Marquand

The health insurance payment system is so complicated that the American Medical Association in 2008 created a campaign called "Heal the Claims Process" and began issuing a National Health Insurer Report Card each year. The 2011 report card revealed an average 19.3 percent error rate in medical insurance claim payments.

You can't fix the medical insurance industry billing system, but that doesn't mean you should throw your hands up in despair and give up. You can help make the claims process go more smoothly on your end by avoiding these common health insurance mistakes:

1. Neglecting to read and understand your health insurance policy.

Know what your insurance policy covers and how much you pay out of pocket. What services are covered? Which providers are in the network? How much is the annual deductible? How much are office co-pays and co-insurance? Understanding the rules is essential to avoiding unpleasant surprises.

2. Not getting prior authorization.

Before you see a specialist or undergo any type of procedure, such as surgery, check with the insurance company to see if it requires prior authorization. If so, make sure the insurer signs off on the procedure before having it done.

3. Using out-of-network providers.

You pay more for services from providers who are not in your health plan network. Double-check whether a provider is in-network before scheduling an appointment. If you must see a provider outside the network, work with the insurance plan to negotiate coverage and find out exactly what your share of the costs will be.

4. Blowing off mail from health insurance companies.

Read mail from health insurance companies and respond to questions. If a new insurance card arrives, throw away the old card and put the new one in your wallet. A new card means something changed, such as a billing address, which could be crucial when it comes time to file a claim. Sometimes insurers mail coordination-of-benefits forms asking about other coverage you have. Respond to questions so the insurer has the information required to process your claim.

5. Giving up before appealing.

A health insurance claim denial isn't the final word. Find out why the claim was denied--sometimes it's just a matter of the insurance company requiring more information. Ask the insurance company how to file an appeal and what information you should supply. If the first appeal is denied, find out why and gather the appropriate documentation to make your case for a second appeal.

Health insurance plans are complex, but by understanding your plan, following the rules, and appealing unfair or incorrect decisions, you can help ensure your claims are paid.