Medical Coding and Billing, Thesis Paper Example

Appeal

An appeal is a written or verbal request by a client to a provider or an insurance company providing medical cover contesting for a decision to reduce or deny him/her some services in the health insurance claim. In most cases an appeal is considered when a health plan does not pay for treatment if the treatment is not covered by the plan but the client feels that the case in question is exceptional or when a physician considers the treatment “medically necessary” (Jaff, 2005).

Reasons why a claim may be denied

There are many reasons that can lead to denials. Some denials result from missing data. For instance, some health plans regularly deny or dishonor claim requests on the grounds of missing information. This can be avoided by ensuring that claim request contain correct patient information. Another cause for denials is lack of good or proper documentation (Jaff, 2005). Every health insurance problem should be accompanied by proper documentation as well as backups to avoid denials. It is necessary for the client to record the names of all the people that she/he has talked to in reference to health insurance plans since these records are valuable when an insurer turns down a claim. Denials also result from ignorance. In this case, the treatment may not be covered under the health plan and thus a claim on the same is denied. In rare cases, a claim may be denied if it is sent to the wrong people. Just like the appeal letters, claim request should be sent to the relevant persons (Armstrong & Terry, 2001).

Importance of an appeal

An appeal is important in that in most cases, when the complaint goes before a state controlled grievance committee, the denial decision is reversed. The customer is thus granted the claims denied by the health insurer. An appeal is thus an exclusive way of reversing a denial decision. It is also a means of regulating a health plan. An appeal eventually goes before the regulating authorities such as the U.S department of Labor or the state’s insurance department and is therefore the surest way of controlling a health plan (Armstrong & Terry, 2001).

References

Armstrong, R. E., & Terry P. R. (2001). Veteran’s Benefits: A Guide to State Programs. Westport, Conn.: Greenwood Press.

Jaff, J. (2005). Know your Rights: A hand book for Patients with Chronic Illness. New   York: Advoc. for Patients w. Chronic Ill.