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The Health Insurance Code: ICD, CPT, EOB and why you should care, p 2

We're continuing our discussion of health care billing codes, the alphabet soup that appears on medical bills and health insurance explanation of benefits forms. The average consumer may not know or pay attention to these codes, but these numbers and alphanumeric character strings are key to understanding why the insurer has denied or delayed payment of a claim.

Floridians pay billions for health care every year. It makes sense to know that we're paying for services we've actually received.

A study by the Government Accountability Office found that many denied claims are reversed on appeal. In fact, a consumer has a 50/50 chance of prevailing in an appeal. The exact odds depend on the insurer, but, overall, the study found successful appeals in 39 percent to 59 percent of cases nationwide.

One woman tells the story of giving birth to her son in the hospital and having part of the claim denied. Her insurer said she needed a prior authorization for the hospital stay. When she called and tried to straighten it out, she had no luck.

Filing an appeal with the insurance company did the trick. She didn't know she could appeal, but someone suggested it, and she was able to obtain retroactive approval for the hospital stay.

Another woman says her insurance company denied a hospital claim, because she had stayed in a private room. Her coverage, it seemed, only applied to semi-private rooms. It took months to explain to the insurance company that the hospital only had single rooms. In fact, it took a visit, in person, to the hospital and a meeting with the hospital's chief financial officer.

It's important to remember, too, that the insurance company may not have the last word. In Florida, for example, consumers who appealed to an outside review organization were able to overturn or to amend the insurer's decision in 49 of 186 instances -- about 25 percent of the time.

The same GAO report covers application denials, but that is a topic for another post on another day.

Source: LA Times, "Health insurance claim denied? Appeal, appeal, appeal," Michelle Andrews, 06/23/2011

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