Insurance Claim Questions

Kithani

Kithani

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ShakyJake said:
Anyone here work (or used to work) medical claim denials? I'm trying to understand what that looks like day to day, and articles only get me so far.

If you'd be open to a short DM and answering a few questions, I'd appreciate it. Stuff like: how a denial shows up, what you do with it, how long one usually takes, when you stop fighting and write it off.

Just looking to learn from people who actually do this work.

Thanks.
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Are you trying to work on systems to “AI” it up on the denial side or on appealing the denial side
 
Dr.Retarded

Dr.Retarded

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ShakyJake said:
Anyone here work (or used to work) medical claim denials? I'm trying to understand what that looks like day to day, and articles only get me so far.

If you'd be open to a short DM and answering a few questions, I'd appreciate it. Stuff like: how a denial shows up, what you do with it, how long one usually takes, when you stop fighting and write it off.

Just looking to learn from people who actually do this work.

Thanks.
Click to expand...
Dude, go get a public adjuster if you're having real problems. My experience is all with property stuff specifically commercial in the construction world, but I would hazard a guess they have PA's that work any types of specific insurance markets.

It's probably pretty damn lucrative for them considering all of the shenanigans with medical billing and what have you, and with it being just a minefield with policy shit, you're better off getting somebody who knows how to walk through it.

The other benefit is you don't have to pay them anything unless they win the claim and they're going to make certain their fee is covered through whatever negotiated resolution there is.

That's just my two cents dealing with insurance companies for the past decade or more. And the biggest thing to always remember is at the end of the day no matter how nice the carrier might be seeming, they're going to try to fuck you one way or the other, and always be the squeaky wheel, because that's the only way you're going to get the grease. They bank on people who just give up, it's the whole the process is the pain deal.
 
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sleevedraw

sleevedraw

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I work UM which typically takes place before a claim hits, but I may be able to be of some limited help. I've DMed.
 
sleevedraw

sleevedraw

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Dr.Retarded said:
Dude, go get a public adjuster if you're having real problems. My experience is all with property stuff specifically commercial in the construction world, but I would hazard a guess they have PA's that work any types of specific insurance markets.

It's probably pretty damn lucrative for them considering all of the shenanigans with medical billing and what have you, and with it being just a minefield with policy shit, you're better off getting somebody who knows how to walk through it.

The other benefit is you don't have to pay them anything unless they win the claim and they're going to make certain their fee is covered through whatever negotiated resolution there is.

That's just my two cents dealing with insurance companies for the past decade or more. And the biggest thing to always remember is at the end of the day no matter how nice the carrier might be seeming, they're going to try to fuck you one way or the other, and always be the squeaky wheel, because that's the only way you're going to get the grease. They bank on people who just give up, it's the whole the process is the pain deal.
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They're typically called "patient advocates" for health insurance.
 
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Dr.Retarded

Dr.Retarded

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sleevedraw said:
They're typically called "patient advocates" for health insurance.
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Cool. I figured there was somebody who did that type of work with medical insurance related stuff.

I just know that anytime I've had projects in the past that had grown and scope forgot complicated due to the carrier, we had a couple of different PAs we could go to to start helping with the situation.

With the construction stuff there's kind of a fine line that you have to walk where you're not acting as an adjuster, but you kind of know where and when to push, and anytime you do you have a job that was going to need some heavy lifting, it was just better to go ahead and get one on board from the get-go.
 
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