Most private payers have a complex set of policies and procedures that govern provider payments. Sometimes, simply determining why a claim has been denied can be challenging. Audits are time-consuming and may carry a large financial risk. And a demand for repayment of already paid claims can put tremendous stress on a medical provider’s business.
It is important to address billing disputes with health insurers methodically. The first step is understanding the insurer’s procedures and deadlines. Often, this process involves combing through a large number of published policies and determining which ones apply to a particular service. Identifying the bases for denial is sometimes straightforward, but not always. If not, obtaining clarification (or documenting the unwillingness of the insurer to provide such clarification) is important.
Once the bases for denials (or repayment demand) and the applicable policies are identified, it is important for the provider to accurately document its position in a communication to the insurer. Many health insurers have processes for appealing payment decisions that must be followed.
Communicating with the correct individuals within the insurance company can also help lead to a resolution more quickly. If all else fails, a provider may need to be ready to exercise their legal remedies through litigation or arbitration.
ASG Law has experience in dealing with difficult health insurance billing disputes on behalf of medical providers.