The Whitworths of Arizona, bringing science to you in everyday language.

Sunday, January 31, 2016

When Your Insurance Claim is Denied

A recent Facebook post triggered this blog. "Wow!"  I thought,"That's really helpful. I'll write a blog about that." But then I researched it and found that it falls into the category of "If it sounds too good to be true, it probably is." Called "Medical Hack," it tells readers who have been denied an insurance claim to call the insurance company, ask for their HIPAA Compliance/Privacy Officer, and demand the names and credentials of all the people accessing your record to make the denial. It goes on to say that almost always, the insurance company to reverse their decision because they don't want the government agencies, or you, to know that non-medical, high school level people are making these decisions. Sounds easy, huh? Well, don't be fooled. Go to and see how they found the post to be mostly bogus.

That said, most of us have had an  insurance claims denied. With the medical concerns connected to LBD, and the confusion around what the disorder can cause, it is something LBD caregivers should be prepared for. provides a well documented, list of things to do about claim denials, things that are more likely to bring results than the above "Medical Hack."

1. Start by making sure the claim is correct:
  • Know your insurance's limitations. If it covers the procedure only in certain instances, does your situation fit? Can you or your doctor make it fit? Wording makes a difference.
  • Get the authorization. Most insurances require a heads up prior to the procedure. Make sure your doctor does this.
  • Show objective evidence of need. Know if there are tests or procedures that need to be done to prove the need for this procedure. The doctor will usually tell you, but ask if this doesn't happen. Make sure the tests, etc. have been done and documented?
  • File in a timely manner. If the doctor's office files the claim, ask to be informed about when the claim was filed with the insurance. If you aren't notified right away, check on it. The claim might be rejected if it was not filed in a timely manner.
  • Pay your co-pay, deductable or patient portion amounts as they are due. Unpaid, this can be a reason for rejection.
  • File everything electronically and keep a digital paper trail as a reference.
  • Conduct all correspondence concerning your claim via e-mail whenever possible. This includes correspondence with your doctor. (Snail mail is fine, too, as long as you keep copies and logs.) If the communication is during a doctor's visit, ask for a record of it from there.
2. If a claim is rejected, it can be appealed. First, find out why it was rejected, fix the problem to the best of your ability and reapply.
  • Make necessary corrections. If it is any of the above, do what is needed to correct the paperwork.
  • Be proactive. The more proactive you are, the more likely you are to get a positive result. Ask specific, detailed questions like whether your claim was filed digitally or physically. Ask for copies of that filing.
  • Correct codes. There may be errors or omissions in the diagnosis and procedure coding. These codes are what the insurance company goes by, more than words! Ask the doctor to rewrite the incorrect information.
  • Get a letter of medical necessity. The insurance company may say there was insufficient medical necessity. Ask the doctor to write a "letter of medical necessity," specifying diagnosis, recommended treatment, and the length of treatment time. This may also work if the claim was denied for lack of prior authorization.
3. If the claim is still denied:
  • Enlist the support of advocates: Talk to the doctor again. Doctors have to deal with such issues all the time and they know the right words to use. The hospital social worker is another good resource.
  • Apply again and again. Because insurances work on a profit basis, the longer they can keep from paying out money, the more profit they can show. The more times you reapply, the higher your chances are of approval.

4. Negotiate. If the claim continues to be denied, the reason will almost always be based on cost.
  • Negotiate a percentage. Learn the true cost of the procedure and negotiate a percentage the insurance will cover if you pay the rest.
  • Move the negotiations down a level. If the insurance won't cover, negotiate with the hospital and doctor. They will almost always be willing to accept a lower payment rather than none at all.
For information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson's and Lewy Body Dementia

Helen and James Whitworth are not doctors. As informed caregivers, they share the information here for educational purposes only. It should never be used instead of a physician's advice.

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