5 Reasons why Health Insurance claims see significant deductions

Health insurance claim is simply a request for payment which the insured or the insured’s health care provider submits to the insurer for items or services which are covered in the health plan. Insurance claims are reviewed by the insurer for their validity and only once approved are then paid out to the insured or requesting party (on behalf of the insured).

Making a Health Insurance Claim

Health insurance claims can be made in two ways:

  • On a Cashless basis – here the treatment requires to be only at a network hospital of the Third Party Administrator (TPA) servicing the policy. Authorization for availing the treatment on a cashless basis needs to done according to the procedures laid down in the prescribed format
  • Claims on reimbursement basis- here the clauses related to the claims in the policy document need to be read, and all the procedures and documents required for making a claim on reimbursement basis need to be understood properly. Post hospitalization one needs to ensure that all the documents related to claim settlement are kept ready like claim form, discharge summary, prescriptions and bills

Significant deductions in claims

While filing health claims either for group insurance plans or individual health plans; certain procedures and things need to be kept in mind so as to accrue adequate benefits from the claims filed. However at times various billing mistakes while filing health insurance claims can cause significant deductions in the final claim settlements.

The health care provider or the person filing the claim to avoid claim deductions resulting in delayed payments, costly fines and loss of revenue- needs to watch out for few common billing mistakes before billing the claims.

  1. Inaccurate or Incomplete Patient Information

The smallest details matter while filing a claim and if not kept in mind can lead to denials and eventually deductions in overall claim settlement. Inaccurate or incorrect details about patient information need to be avoided and the person filing a claim may miss various minute details resulting in reduction or delay of claim amounts.

Simple inaccuracies in patient information which can lead to claim deductions include- name spelt incorrectly, wrong date of birth, group number not entered, diagnosis code not corresponding with the procedure performed, and so on. Due to this claims payments get delayed and total claim settlement gets reduced.

  1. Procedures not covered 

It is a possibility that the procedures one had weren’t covered by the health insurance policy, though one may believe that it is covered. Hence before filing all health insurance claims; the terms of policy need to be properly checked; as some plans don’t cover certain categories of care, such as infertility treatments or dental surgery.

  1. Poor Documentation

This can negatively affect the claims process; this happens if the provider has provided incorrect, illegible, or incomplete documentation of a procedure or patient visit. In this case it becomes difficult to make an accurate or complete claim. Moreover in such a case the person filing the health insurance claim or the medical biller must contact the provider to get the correct information.

  1. Upcoding or Unbundling

This involves not giving the accurate idea of a level of service or procedure involved. This can be done by error or at times to receive higher reimbursement rates. Upcoding occurs when codes for services a patient did not receive, or codes for more intensive procedures than the provider actually performed are entered. It also occurs when a service performed is not covered but instead a covered service is billed in its place. It may be done in an attempt to receive more money from the insurance company.

Unbundling is billing for procedures separately which are considered as all inclusive. For example- when a person files a claim; bills for two unilateral screening mammograms, instead of billing for one bilateral screening mammogram. When finally it is reviewed by the insurance company it results in denial of the claim amount.

  1. Duplicate or Wrong Billing

When the claim is filed for the same procedure, test or treatment more than once it results in duplicate billing. While mistakes like billing for a wrong service or a procedure or test which was cancelled but never removed from a patient’s account result in wrong billing.  Generally these errors occur due to simple human errors; but various facilities may even be fined for fraud each year for such mistakes. Fraud is considered as willingly and knowingly filing medical claims that are inaccurate.

Besides these there are several other reasons why health insurance claims see significant deductions such as- procedures which usually require pre-authorization filed without the same, failure to verify insurance, wrong codes, billing mistakes, transcription errors, etc. Chart audits are good preventive measures which can be adopted to reduce inaccuracy and increase claim payments. Also there are several group health insurance plans which offer an easy claim settlement process; enabling quick and speedy settlement.

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