Many people feel adequately protected by their health insurance coverage, only to find out they are not covered when injury or illness strikes. When claims are denied, patients are often left with exorbitant medical bills that are impossible to pay.
High-Risk Factors for Health Claim Denials
Incorrect Hospital Admission Status
When admitted to a hospital, a patient is assigned a status, either observation status or inpatient status. If a patient is assigned the wrong status, an insurance company may refuse to pay the claim for the hospital stay. Observation patients are considered outpatients, even if they stay overnight. Inpatients typically require a two-night stay or longer. An insurer can deny a health claim if they feel the hospital admitted the patient under the wrong admission status.
Many health insurers require pre-authorization for certain medical tests and procedures, but that doesn’t automatically mean they will pay for them. Many insurance policies link health benefits coverage to member eligibility and medical necessity for the patient. If the insurance company decides after the fact that a test or procedure wasn’t medically necessary, they can refuse to pay the bill even though it was pre-authorized.
Required shots and vaccines for traveling outside of the country may not be covered by a health insurance company. While most insurance policies cover routine vaccines for preventive health care in the U.S., vaccines for foreign travel are commonly not covered under insurance plans. People who plan to travel to a foreign country typically experience claim denials for required shots and vaccines.
Most health insurers will not pay for healthcare costs related to injury or illness from illegal activity. Many companies have an illegal act exclusion clause written into the policy that allows them to deny claims caused by illegal acts such as violence and drug and alcohol use. Some states don’t allow illegal act exclusions and prevent insurers from writing coverage restrictions based on the influence of alcohol and/or drugs.
Nursing Home Care
If a patient has spent at least three days as an inpatient in a hospital, some private health insurance companies and Medicare may pay for short-term rehabilitative nursing home care. However, neither private insurance nor Medicare will pay for long-term nursing home care without a long-term care policy in place.