We have all heard horror stories about an insurance company refusing to pay off on a claim due to some oversight by the policyholder. In an effort to protect them against fraud, insurance companies pay hundreds of thousands of dollars annually to investigators and claims adjusters. These employees man the front line against fraudulent, and unscrupulous claims, which, in a perfect world, helps to stifle the high cost of health care insurance and result claim denials in which you spend thousands of dollars dealing with.


The sad part is when honest people with legitimate claims get caught up in the red tape of an insurance claim investigation. Policyholders can often wind up being denied their claim due to some small oversight, or policy stipulation, that they were not aware of prior to the claim being made.


Knowing and understanding how insurance companies and their investigative teams function will be invaluable to you should the day come when you must file a medical claim.


By taking these precautionary steps you may be able to avoid going to battle with your insurer over medical costs you believed should have been covered.



  • Examine all provider documents carefully. This is a “cross your t’s and dot your i’s” step you can take to ensure that all of the information on those long forms you fill out at the doctors office is accurate. Name spellings, addresses, insurance policy numbers, date of birth, employee name, etc. As soon as next year, new government standards will allow patients increased access to their health records via computers, and they will be able make online corrections, and updates as needed.


  • Understand the new IC-10 Coding System. With over 55,000 additional codes being added the potential for mistakes in this area could be high. Something as simple as a code being given for injury to the left side of the body when the injury is actually on the right side is just enough to disqualify your claim.


  • Always carry your most recent health insurance card. Insurance companies will often send out new insurance identification cards when they have made changes to your policy. Discover what changes have been made in their services, and always replace your old card to avoid surprises.


  • Make sure that all of the health services being provided to you are from agencies that are in-network. There is an important difference between asking; “Do you take my insurance?” versus “Are you in-network with my insurance company?” The latter will provide you with the greater cost savings.


  • Find out if the procedures you are to undergo require prior authorization and make sure the authorization is granted before accepting the procedure. This takes very little time, but may end up saving you thousands of dollars in unnecessary costs.


There are many actions you can take to help protect yourself from a denied claim. It is up to you to do the due diligence, and to understand what your policy does, and does not cover. The best advice is not to leave anything to chance when it comes to understanding your medical coverage.


To prevent having claim denials let HPC Billing take care your medical billing for you!  Give us a call today (888)517-4992.  Make claim denials a thing of your past!