If you’ve had a health insurance claim denial or a pre-authorizationrequest denied, you probably want to know why. There are literally hundreds of reasons for a health insurance claim denial, some more common than others. Unfortunately, one common reason for having a claim or pre-authorization request denied is a simple screw-up.
Here, I'll share some examples from the time I spent reviewing pre-authorization requests for a managed care company. Although I’ve changed specific identifying details to protect patient privacy, the basic tenents of these examples come from cases I actually reviewed, cases where a simple screw-up resulted in a denial.
Wrong Demographic Information
Insurance reviewers try to confirm at least two pieces of demographic information to ensure they match the claim or pre-authorization request with the correct health plan member. In other words, they want to make sure they have the correct patient. For example, they may check the patient’s full name and also his or her birth date. Depending on the insurer, other identifying information such as social security number or address might also be allowed as the second identifier.
If the person reviewing the claim or pre-authorization request can’t match up two personal identifiers, then they can’t process the claim or request. If not corrected, this will become a denial.
Here’s an example. A patient’s full name is John Quincy Adams. His health plan has him listed as John Q. Adams. However, since he goes by Quincy, not John, his doctor’s office submits the claim for Quincy Adams.
To the claims reviewer, it appears that a claim has been submitted for someone who isn’t even a health plan member. They have hundreds of members with the last name of Adams, but none of them have the first name of Quincy. If the mistake isn’t corrected, that claim will be denied because of a silly mistake.
Wrong Clinical Information
Frequently, insurers and managed care reviewers need clinical information to make the decision to pay a claim or to pre-authorize a requested service. Sometimes this clinical information comes from speaking with someone at the doctor’s office. Other times the information comes from your medical record. It’s common for your doctor’s office to fax or convey electronically the parts of your medical record the insurance company needs to see.
Here’s an example of a silly mistake in this process that can cause a denial. On Monday, you see your doctor for a foot problem. He feels you need an MRI of your foot and requests pre-authorization for the MRI from your insurer. On Tuesday, you’re back in your doctor’s office with a migraine. A few days later, the insurer notifies your doctor’s office that they need some clinical information about why you need the foot MRI before they can pre-authorize it.
The busy office staff sends the results of a foot X-ray which was normal. (That’s why you need the MRI, because the X-ray didn’t tell your doctor what was wrong.) The staff also sends the record of your last office visit. Unfortunately, your last office visit was for a migraine, not a foot problem.
When the health insurance company’s reviewer reads the clinical information submitted, it appears that your doctor wants an MRI of your foot when you came in complaining of a migraine headache. The foot X-ray was normal, so, without further context, it doesn’t help. Since there’s no logical reason why a foot MRI would help to diagnose or treat a migraine headache, your request is denied.
Duplicate Request
You see your primary care physician for a knee injury. She refers you to an orthopedic specialist and requests pre-authorization from your health plan for a knee MRI. Three days later, the health plan approves your knee MRI.
The day after the MRI approval, but before you’ve had the MRI scan, you have your appointment with the orthopedic surgeon. He confirms that you need a knee MRI, and his efficient office requests pre-authorization before you’ve even left the exam room.
When the insurance reviewer gets the orthopedic surgeon’s request, it appears that he wants an additional knee MRI since the one ordered by your PCP was approved just a couple of days ago. Without further information about why you need a second MRI on the same knee just days later, and without information about what the first MRI showed, the reviewer denies the second request.
This results in your orthopedic doctor’s office getting notified that your request for a knee MRI has been denied, while your PCP’s office has already been notified that your knee MRI has been approved. Your PCP thinks everything is fine, while your orthopedic doctor is frustrated that your insurance company won’t approve a knee MRI. You're stuck in the middle and don't know who to listen to, the PCP saying your MRI is pre-authorized, or the orthopedic doctor saying your health insurance company is being uncooperative.
Wrong Provider
If you have an HMO or an EPO plan, you’re required to use certain health care providers if you want your health plan to pay for the care. If you don’t use a provider in your health plan’snetwork, the plan won’t pay. Here’s an example of how this can result in a claim denial.
You had a suspicious finding on a chest X-ray last year, and you’re having a series of CT scans to follow that finding. You’ve gotten 3 CT scans so far, and you had all three at the same imaging center—the one across the street from your doctor’s office.
However, on January 1st, that imaging center’s contract with your health plan expired. Since it hasn't been renewed. It’s now an out-of-network facility. Your health plan doesn’t pay for out-of-network care.
If that’s the facility you submit with your request, you’ll get a denial because your health plan no longer works with that facility. In this case, it’s not that the reviewer is saying you don’t need the CT scan. Instead, she’s saying the insurer won’t pay for you to have the scan at that particular facility. Pick and in-network facility if your health plan requires it.
The Take-Home Lesson
If you get a denial, don’t assume that the health insurance company won’t pay. Denial appeals were designed to provide a chance to take a second, often closer, look. In some cases such as the John Quincy Adams mix-up where the insurer couldn’t match the information on the claim with any of their known health plan members, you don’t even need to go through the appeals process. You can just submit a new claim with the correct information. As the above examples prove, sometimes silly mistakes are all that’s preventing you from getting your claim paid or your request approved.
