Five Reasons Healthcare Claims are Denied

Navigating the healthcare claims process can be challenging for employees. Delayed claim payments and denied claims make it even harder for employees to manage their health care. Let’s dive into the most common reasons why healthcare claims are denied.

Five Reasons Healthcare Claims are Denied

According to HR Magazine, many claims disputes arise from five common problems that are not only easily resolved, but also often preventable.

1. Health Plan Cards

Often, claims issues stem from the employee not providing their current health plan information during their health care visit. This could be because employees lost the new insurance card, forgot to show the provider the new card, or didn’t provide insurance information at all.

Solution: When distributing new cards, remind employees to keep it with them, dispose of old cards and always show the card when seeking health care. Follow up with regular reminders throughout the year.

2. Providing Information

Insurers want to ensure that injuries are not work-related, which would eliminate their responsibility to pay. Many claims get delayed while insurers conduct an investigation into the cause of the injury; this can be avoided if the employee answers the insurer’s questions and makes clear if the accident was outside work.

Solution: Educate employees about the importance of providing the insurer with any needed information, which can be as simple as returning a phone call. Emphasize that this step will speed the claims process.

3. Provider Error

Sometimes, a claim is denied simply because the provider coded it incorrectly—for example, attributing a claim for circumcision to a mother, rather than her newborn son. Another reason could be that a provider failed to indicate that a particular therapy or treatment is medically necessary.

Solution: When inquiring about a denied claim, be sure to check that the claim was coded correctly. If it was an error on the physician’s part, ask the provider to resubmit the corrected claim. Also, encourage your employees to know their benefits and act accordingly—for instance, knowing if therapy is covered only if deemed “medically necessary,” and then ensuring their provider indicates it as such.

4. Double Coverage

Employees who have coverage through two plans (theirs and their partners) may be confused as to how their dependents are covered, which can lead to mistakes regarding which insurance information they give their child’s provider or cause disagreement between the two insurers regarding who should pay.

Solution: Educate employees about navigating double coverage situations; for instance, children generally have primary coverage through the plan of the parent whose birthday comes first in the calendar year. Give other specific examples to help employees understand their coverage.

5. Benefit Confusion

Health care claims confusion can result from insufficient or overly complex communication from the employer. Benefits are confusing for employees to start with, and benefits communication documents are often written at too high a level to make sense to many employees. This either results in employees misunderstanding their benefits information or failing to read it at all due to its complexity.

Solution: Help your employees understand their benefits. Communicate in clear, direct ways and provide multiple opportunities for employees to learn and ask questions. Make plan documents available to them year-round, coordinate benefit meetings prior to open enrollment and make available other resources for employees (carrier website, online or phone support, your company website, HR, etc.).

Recap

In addition, employers and HR professionals should remember to tap into their independent insurance agent as a resource when trying to sort out a problematic claim situation. If you have spoken with the insurer and made no progress, we may be able to facilitate a productive conversation and get to the bottom of an issue. If you have any questions at all, contact one of the members of the Thams Agency team at team@thamsagency.com.