By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
January 29, 2025
Filing an appeal is a good strategy to get things out of your insurance… except when it's not!
Let’s explore 5 good reasons when filing an appeal is neither right nor your Right as an health insurance member and Patient.
A. What is an “appeal’?
· It is a request sent to an insurance company asking for their review of a decision, of a denial of coverage or authorization, or to reprocess a specific claim.
· It is your Right as a member, per the terms of your policy
· It is also the Right extended to Patients under Federal laws.
· Filing an appeal is also the provider of services' Right.
B. No right to appeal
But filing an appeal for any and all reasons will not always get you the outcome that you desire as some reasons for denials, rejections or incorrect claim processing allow you NO right to appeal:
1. Incorrect Patient Data Entry:
· If the patient’s demographic information is incorrect, invalid or missing, such as date of birth of a patient, or relationship to the subscriber, there is no right to appeal as it must reject incomplete or incorrect claims due to someone else's fault
· Same thing if the subscriber’s demographic information is incorrect, invalid or missing or if the insurance ID number does not match. Of course, if the wrong insurance is billed, there is no right to appeal.
· If the patient has 2 insurance policies, billing the wrong carrier or order would result in denials with no right to appeal.
2. Coding Errors:
· Missing or invalid providers' tax ID numbers, individual personal ID numbers (“NPI”) or contact info occur too often, especially for Out Of Network services.
· Incorrect or missing procedure, diagnosis or place of service codes would not be eligible for appeals. A description in not enough! If you are paying upfront and cash for medical services, but the invoice you submit for reimbursement is illegible, incorrect or incomplete, don’t expect a right to appeal. Your insurance did not make any mistake if it cannot process the paperwork.
· If your provider did not submit clinical medical records, indicate an authorization number or respond to a request from your insurance for documentation or additional information, the right to appeal may not be available
· Coding mistakes on the part of a provider can also lead to incorrect processing or denials that cannot be appealed until corrected. For example: coding a cholesterol blood test with a osteoporosis diagnosis or an appendectomy with a breast cancer diagnosis lead to denied claims with no right to appeal.
3. Patients’ Errors:
· Not responding to questionnaires or requests for details/clarification lead to denials or rejections without the right to appeal. Why the ER visit? Is a third-party liability involved? Is this injury workers comp related? Do you have another health insurance policy? The insurance cannot process unless informed.
· Non-payment of premiums offers no right to appeal unless you can prove they were paid on time.
· HMO members billing the wrong payor: HMO is the organization providing a type of health services where a primary care physician supervises and provides most of the medical care, or issues referrals authorizations when services need to go outside of that office. That medical group (or “IPA”) usually pays medical bills, but under certain circumstances the actual insurance company must cover those costs. Some could include: emergency care, out of area services, or special authorizations. Rejections of responsibility would offer no right to appeal, if the wrong payor is billed.
· If a patient has more than one policy, “Coordination Of Benefits” must be established between carriers to determine which pays first. Billing the wrong order/plan offers no right to appeal.
C. Solutions
1. Correcting an error or provider requested or necessary info/documentation/code should re-start the process, and ensure positive results…
2. … but the proper entity must correct its own errors in a timely and appropriate manner
3. While filing appeals remains an excellent tool to force insurance payments, your plan cannot comply unless it can process a claim submitted according to medical billing protocols, coding requirements, documentation submissions and “clean” invoicing.
4. Helping the insurance help you is the most effective way to get to a successful outcome. Filing an appeal when there is no Right to Appeal will only bring further delays, frustration, lower chances of success and unexpected medical bills.
In a nutshell: only appeal when the insurance is at fault. A patient's or provider's mistake or oversight offer no Right to Appeal.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2025 @ the medical bill whisperer 2025™
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