Texas Tech University Health Sciences Center
Diligence with Insurance

Diligence with Insurance

diligence-with-insurance- image0I enjoy reading John Grisham novels.  Do you remember his book titled “The Rainmaker?” It was a story about a young lawyer in Memphis taking on a health insurance company that had made a deliberate decision to deny most claims. The company reasoned that most claimants would give up in frustration.

I refuse to be an apologist for insurance companies, but I really have not seen any as unscrupulous as the one in Grisham’s novel. Nevertheless, this week, I did see a claim denied because an extra blank space was placed at the beginning of a series of numbers.  (I understand computers use binary code and things have to be in the right place.)  But, the point is — insurance companies will certainly not make it easy on us.  Therefore, we have to be smart and submit the claim the way the insurance company wants it.  Because once any payment is denied, it creates a problem.

In studying our data, here are some common reasons why Texas Tech Physicians claims are denied:

1. Duplicate claims. This is a common mistake which accounts for a large percent of claim denials; basically, this is when a claim is resubmitted after not hearing back from insurance companies, which resets the clock on the time it takes to pay a claim.

2. Lack of information. Basic information, like a person’s birth date or name spelling, is often wrong. When these claims are denied, it almost always doubles the time it takes to turn around a claim, affecting the practice and the patient.

3. Expired eligibility. Texas Tech Physicians’ best practice is to verify coverage beforehand to avoid these issues. One of the most common claim denials involving verification is when a patient’s health insurance coverage has unknowingly expired.

4. Claim not covered by insurer. Another claim denial that can be avoided with verification is when an insurer does not cover procedures.

5. Time limit expired. This is the most easily avoided claim denial. We do our work in a timely manner — including service-to-posting times and completion of the electronic health record.

Texas Tech Physicians pre-screens claims, but it takes real diligence to avoid costly denials. Every minute spent getting claims right the first time saves three times that amount of time on the other end dealing with a denial.