In this video Matt Koppin of BenefitsMedicare.com and Piedmont Insurance Services explains why many medical insurance claims are delayed or denied and offers practical steps for consumers to resolve the issues. He identifies the most common sources of problems: provider‑front‑desk mistakes such as outdated or incorrect insurance information, miscoding of services, and failure to forward claims to the billing department; insurer‑side data mismatches like incorrect member IDs or claim numbers; and prior‑authorization failures where either the provider or the insurer did not obtain the required approval. Koppin also notes the impact of HIPAA restrictions, which limit the type of communication insurers can have with patients, pushing the burden onto policyholders to verify claim status. He advises consumers to (1) contact the provider to confirm the correct insurance on file and that a claim was submitted, (2) call the insurer to verify the date of service and receipt of the claim, and (3) never pay a medical bill until the claim is confirmed as processed. He offers his firm’s assistance and provides a phone number for further help.
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Handling claims is the complex situation for about anyone. We handle insurance claims for a lot of folks, and more often our clients now see more of their claims not getting processed or approved more than ever. So we can kind of go through each step process and from For instance, like doctor offices, they are the primary issue nowadays regarding claims. They usually never file the claim, primarily because the front desk office never submit the insurance documentation either correctly or over to the billing department so they can be filed properly. Or they send in old insurance information from the billing because they never get it updated, as well as they may make incorrect coding. Undocumented on the claim, so the codes don't match up to what should have been actually performed, as well as they may adjust the claim to be processed. And if they don't make changes and updates to it, the claim, the right person may never get the correction in the process either. So the claims adjuster, things like that, won't get the information to be able to handle the claim. And instances where insurance companies create the issues as well They do not see the claim for the right person, or like the claim number, and, uh, I guess the insurance carrier's member ID or insurance ID doesn't show up properly, and they have to correct and get that information corrected in the provider's office so they can get that information done properly, and that way the claim can get processed and paid properly. Now, prior authorizations issues sometimes form where either a doctor or insurance company didn't authorize the procedure, meaning they never did let you know that the claim should have been covered, or if the claim needed to be covered, they never were notified about that. So sometimes those procedures end up not getting paid because they weren't verified. And that's what's happening more and more. And apart from receiving the codes, when I forward claims to proper carriers when they received. And so, and if a different department gets it, if they don't want to, they don't have to. A lot of times you'll see that they won't file the claim to the claims department. You just gotta make sure it gets to the right places and the providers are sent to the right address as well. But more and more issues as far as getting claims approved, uh, you know, verify the information. So one thing you want to do when you first find out a claim is getting an issue or you get a bill in the mail, a lot of times call your provider, make sure they got the correct insurance information on file and that they have tried to file a claim on the particular bill that you're looking at. Because you may find out that they don't have the insurance information properly and they may have an old insurance company, and that can fix the problem just about instantly., and then they can reprocess the claim to the insurance department. Now, on the other side of it, the insurance company receives the information. You call them, say for instance the provider, the provider states that, oh, they do have the right insurance information in regards to this. The insurance carrier can actually verify to you if they have that right date of service. A lot of times on date of service, you'll find out too that when they have that right date of service, it'll file It'll show up and whether it's in the process or not. So, you know, one thing about the process and the situation is the process will continue to go through several different steps before it gets paid and claimed to be, uh, you know, basically submit a payment to the provider. So sometimes it might be in the process, it's just taking a little time to go through. One thing about the insurance industry is it's getting more and more complex. And what I mean is the HIPAA law. The HIPAA law is really pressed down in the last 10 years on agents servicing their actual clients. Now we have a lot of documentation to talk with insurance companies and verify you, but it's getting harder and harder for us to talk to the insurance companies. They got us down to where we can say, you know, yes and no questions. And most time when doing these kind of situations, more and more the policyholder will have to be start calling the insurance companies or in the provider. So in regards to all that, we're trying to help a lot of our clients over these years, uh, figure out the best solutions of how they can, you know, save money, save time. But in this case, in regards to claims, I would never pay a bill until you've really verified that your insurance company is actually listed properly. It's been filed to the proper address, and then making sure the insurance company has actually received it on their side. Now, anytime you're doing any claims issues, you know, you're welcome to reach out to us, um, and we can actually help you. But that's what we're here for. We're here to service and help you in any way we can. And my name is Matt Koppin. I'm with BenefitsMedicare.com and with Piedmont Insurance Services. But you're welcome to call us at 1-888- 779-5038. Appreciate your time and hope you enjoy this video. Give us a thumbs up if you like it. Thank you.
