This is a ‘hack’ that has been going around on Facebook that is so full of misinformation and fallacies that I felt the need to address it. People should not be allowed to post bogus medical information on Facebook.
The writer of this hack appears to have not done any research into how insurance companies really do process claims. My research comes from having worked eight years as a customer service representative in a health insurance company, explaining how claims are processed, why they deny, and what can be done to contest a denied claim.
First of all, you need to know that no one who is not trained in HIPAA is going to be reviewing a claim. EVERYONE from the lowly high school graduates to the CEO is REQUIRED to go through HIPAA compliance training in order to work at the company.
By the way, HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.
Second, you need to know that claims do not get denied because of HIPAA violations. The only thing HIPAA has to do with claims processing is ensuring that your data does not get shared with anyone not authorized to have it.
Therefore, the funniest thing I read in this ‘hack’ is when the writer advises people to ask for the “credentials” of everyone viewing claims. There is no “credentialing” process beyond the required HIPAA training that gives employees an official license or degree that authorizes them to process claims.
Training completion is recorded in the employee’s records and they sometimes receive a certificate upon completion to hang in their cubicles to let others know what they’ve been trained in. So, if you ask for ‘names and credentials’ of everyone authorized to view claims, you’d have to be prepared take down thousands of names, depending on the size of the company. That is, if you could get the names.
Because you know what? Employee records are also privacy protected so the company cannot release employee names or ‘credentials’ to anyone who calls and asks for them. So, if you’re thinking about following this hack, prepare to get absolutely nowhere. And very likely laughed at after you hang up, if not before.
Third, insurance claims processing and customer service are not minimum wage jobs like those in a telemarketing call center where anyone can do the work, as the hack writer would like you to believe. If you think that a high school kid who has just graduated and has had no college education or post-high school training would be hired to work as a claims processor or a reviewer who makes “medical decisions”, you’re just as mistaken as the writer of this hack is.
Since it’s fairly easy to lose a good-paying job with good benefits for even the slightest HIPAA violation, it’s very unlikely this is going to be a basis for your claim denying. If you’re planning to play this ‘HIPAA Violation’ card to get your denied claim re-processed, you are in for a BIG surprise!
By now, it should be clear that the person who wrote this ‘hack’ has either never tried this herself nor researched it with anyone who knew something about claims processing.
So, if it’s not HIPAA violations or untrained high-school grads given the power to make medical decisions, then why do claims get denied?
Here are the biggest reasons, roughly in order of the frequency in which they occur:
- No pre-planning by the patient (that’s you!)
The patient does not read the coverage manual that every insurance company is required by law to give to their enrollees, nor do they call the customer service department of the insurance company to verify that a procedure is covered before they have the procedure.
NOTE: Customer service representatives can legally only verify coverage per the coverage manual. They cannot evaluate medical procedures or situations nor can they ever guarantee coverage.
In fact, every insurance company’s recorded greeting advises that they cannot guarantee coverage. You can rely on the information in your coverage manual for common or routine procedures but more complex procedures require more research. (See below on ‘prior authorizations’)
- Health care providers (doctors, nurses, lab technicians, etc) tell patients procedures will be covered when they don’t know for certain themselves.
Don’t let a provider tell you, “Oh, don’t worry–your insurance will cover that.” Check your insurance manual or call the company. Health care providers don’t read insurance manuals and are not the ones who submit claims; the clinic or hospital’s billing department does that.
- Some complicated, very expensive, or recently-approved procedures require what is known as a ‘pre-authorization’ or ‘prior authorization’ (also called a ‘PA’ or ‘pre-auth’ or ‘pre-cert’ by health care billing staff)
This involves your health care provider submitting a report of your condition and their plan for treatment (surgery, therapies, or prescription medication). This plan is reviewed by a team of physicians and medically-trained staff at the insurance company to determine if the plan will provide for a positive outcome on your health.
A PA can take quite a bit of time to approve, especially for a recently-approved or very expensive procedure that may require a great deal of documentation and time for review.
DO NOT ever let your provider say, “Aw, let’s just go ahead and do it, I’m sure they’ll approve it” unless you have thousands–maybe even millions–of dollars to cover your procedure if the PA is not approved after you’ve already had the procedure. You do have the right to appeal the denial based on “my doctor told me it would be covered” but don’t expect to win the appeal.
- Incorrect coding submitted by the clinic or hospital billing department
Billing departments use numeric codes for diseases and conditions and for the procedures done to treat them. Coders pull the treatment information from the patient’s records then look up the codes for the illness and the treatment and submit these on the claim
Coders and billers are regular people, and regular people are known to misread or transpose numbers if they are hurried, overworked or fatigued and submit an incorrect code
They may be in a time crunch because there are time limits on when claims must be submitted. They may be reading too quickly and see ‘angiogram’ in the chart but pull up the code for an ‘angioplasty’. The first is an imaging procedure, the second is an operation. If the procedure code applied is not one that would be indicated for the treatment of the condition, the insurance company computer will deny the claim for “procedure does not match the condition.”
Items (b) and (c) can often be fixed by calling your clinic or hospital and asking them to review the claim for possible errors. You can’t tell them they made an error and they’d better fix it because you are not trained in clinical billing; you can only request them to review it. Most of the time, they will see the problem and correct it.
DO NOT EVER ask the billing office to change a code for an uncovered procedure to one that is covered. It’s unethical not to mention illegal, so they can’t and won’t do that because they could lose their jobs. Also, DO NOT ask the insurance company representative to tell the provider to change a code–the same applies to them as well.
Insurance companies have provider service representatives (PSR’s) whose job it is to work directly with the clinics, hospitals, nursing homes, pharmacies, therapy centers, and medical supply stores to resolve problems with claims.
When you receive a notice from your insurance company that a claim has been denied, you can call your clinic or hospital’s billing office and ask them to work with their PSR at the insurance company to resolve the issue.
DON’T let the provider or billing clerk tell you that you have to call your insurance company and ask them to reprocess the claim. The insurance company cannot change information on claims–only the provider’s billing office can do that.
- Computer-denied claims
Forms are used to submit claims that are then ‘read’ by the computer, much like the scanner that reads numbers from a bar code at the grocery store.
Billers may enter characters like a dot or a dash in a number where there is not supposed to be any character so the computer misreads the code or rejects it completely, resulting in the claim being denied. This too can be fixed by the billing department and resubmitting a corrected claim.
There you have it. These are the most common–and REAL–reasons why a claim might deny and what you can do about it.
Save yourself, your health care providers, and your insurance company a lot of time and headaches by completely disregarding the above misguided hack for getting your claims reprocessed.
Oh, and by the way, there is no such thing as “the US Office of Civil Rights” at ocr.gov. so don’t try looking there for information–you won’t find it.
If you have any questions or comments, please submit them in the ‘envelope’ provided below: