Medical Claim - An Overview

Today, the rising costs of health care have caused a great financial crunch on insurers and employers. For this reason, insurance companies try to find any possible excuse to deny your medical claim, regardless of how minor the medical claim may be. However, there are ways to prevent the refusal of a medical claim and the burdensome bills from your doctorÂ's office.

For the approval of a medical claim, the mandatory requirement is that there should be a medical necessity for a patientÂ's visit to a doctor. A primary reason, due to which an insurance company will deny your medical claim, is lack of medical necessity. Unless you have experienced symptoms that seem major to you, you should try to take care of your medical needs with the use of over the counter medicines.

If you have visited a physician or a doctor and received a bill for services rendered with a notation on the bill that reads Â'Your insurance company has denied the claim, please payÂ', the first thing you should do is to contact your insurance advisor. Often, the insurance company will send you an EOB (explanation of benefits). This is a statement that guides how they processed your medical claim and must include a valid reason for denial of your medical claim.

If you do not receive such a notice, call them. They will explain to you why the claim has been denied. The next phase is to determine how to manage the claim denial.

Sometimes, the reason for the claim denial is not a fault of yours. Many doctorsÂ' offices today don't bill out medical claims. Instead, they hire a billing company to submit their medical claims for them. This helps to somewhat relieve them of the administrative burden of running a health organization. On occasion, medical claims are billed incorrectly or coded wrong.

Keep in mind that if your medical claim is refused, it is not always the doctorÂ's fault. So, before you take action, just plan your work beforehand. But the important thing is to assess how your plan will work in actual practice. If you are enrolled in an HMO (Health Maintenance Organization), the plan states that you must obtain a referral from your PCP (Primary Care Physician), to visit a specialist such as a Cardiologist.

If you visit a specialist without a referral, the insurance company will deny your medical claim. If you have met all the terms and conditions of your insurance company and have still received a denial for a minor medical claim, then talk with your insurance advisor and request for an appeal.

Most insurance companies have a three-step appeal procedure for you to take advantage of. The good news is that most minor medical claim denials are eventually re-processed and paid out, which in some cases leaves patients as insurance policy holders with only small co-pay amounts as their payout responsibility.