Introduction

Denied insurance claims can lead to serious financial and healthcare consequences, including substantial debt and discontinued medical care.

Purposes

This article covers some of the basic topics related to denied insurance claims and surprise billings and can serve as an outline for a Member Services conversation you can have with a Navigator 24/7.

Table of Contents

Common claim issues

Surprise Billing

The term "surprise billing" refers to situations when customers have received bills for medical care they thought was going to be covered but were not covered by their health insurance. This is most frequently encountered when people are on vacation or in new locations and have to seek urgent treatment from medical providers not covered by their insurance.

Denied Claims

Sometimes insurance companies will deny claims in error. Incorrect data may have been entered or introduced to records by medical providers or other parties along the way. Claims can also be denied as a result of other conditions such as failing to pre-qualify for certain procedures.

Underpaying Claims

In some cases insurance companies will pay a contribution towards an insurance claim but perhaps not the amount expected. This may also be true when there is more than one insurance company involved.

Resubmissions

It may be wise to investigate any surprise, denied or underpaid claims and promptly resubmit for payment where appropriate.

What you stand to lose

Healthcare

Denied claims can lead to disrupted care under some conditions, especially when the necessary care is not otherwise accessible.

Money

Denied claims can lead to substantial medical debt and even bankruptcy under some conditions.

Time

Healthcare and insurance problems can often be time consuming because they involve multiple organizations (such as hospitals, doctors and insurance companies) trying to resolve disputes with each other over payment for services in a highly bureaucratic environment.

Peace of Mind

It can be challenging and emotionally distressing to try to resolve complex issues involving multiple regulated organizations while one is already seriously sick, injured or disoriented due to healthcare issues.

Member Services

Noble Navigators provides guidance, direct action and ongoing support services for more than a dozen important life situations, including providing care for others. If you or someone you know needs assistance, please contact Noble Navigators 24/7 for live assistance

Behind the Scenes Information

Insurance companies are highly regulated organizations for a reason. The services they provide to consumers directly affects both healthcare and financial stability. It is important that consumers make informed decisions when it comes to selecting and using health insurance.

Key Terms

Insurance Claim

A request to an insurance company for payment for services.

Benefits

The services an insurance company is willing to provide.

Network

A list of medical providers an insurance company is willing to work with.

Resubmission

Submitting an insurance claim again after it has been previously denied.