HomebusinesshealthAwards and RecognitionbusinesshealthResourcesBlog
The Callery Group
About UsOur ServicesContact Us

Claim Denied
Consider these 8 ways to avoid rejected benefit claims

A group benefits plan is designed to protect employees in their time of need. It is where people turn for the funds to cover medical expenses, offset wages lost because of an injury or illness, or care for family members after the death of a loved one.

It explains why plan holders can be so upset when claims are denied.

There can be a number of reasons for the bad news, which comes in the form of a document known as the Explanation of Benefits (EOB). But many of these situations can be avoided by paying attention to a few common pitfalls.

Consider these 8 tips to avoid the unwanted rejection letters:

1. Complete gait tests before ordering orthotics

There was a time when orthotic shoes could be ordered with nothing more than a note from a family physician, but insurers began to increase restrictions in the fight against questionable claims.

I remember one year when the employees at a mid-sized manufacturer submitted $20,000 in receipts for orthotic shoes, even though they had not submitted a single claim in the previous year. They didn't face a sudden epidemic of foot problems. Instead, employees had responded to flyers from a local shoe seller who learned that orthotic shoes were covered by the company's benefits plan.

Benefits plans will still cover orthotic shoes for those in need, but each claim has to be supported with paperwork from a podiatrist, chiropodist and doctor. The specific challenges also need to be diagnosed by a thorough gait test, which can take a half hour or more.

The shoes themselves cannot be selected off a shelf, either. Each pair needs to be customized for the patient.

2. Make sure your formulary covers travel vaccines

Remote destinations present unusual health risks. It's why many business travellers protect themselves with vaccines before hopping on a plane. Twinrix, for example, will protect against the threats of hepatitis A and B. Typhoid vaccines may be required by those who will be exposed to potentially contaminated food and water for more than a month. (Details about recommended travel vaccines can be found at http://www.phac-aspc.gc.ca/im/travelvaccines-eng.php.)

A drug plan's formulary will list every drug or vaccine that is covered.

3. Use the right calendar when calculating maximum benefits

Every year has 365 days, but the maximum claims for vision care are often based on a "rolling" calendar. If the limits are based on a 24-month period, someone who claims the maximum amount mid-way through a year will have additional claims denied for the next 730 days.

4. Know if your dental plan covers caps, crowns and cosmetics

Nothing can brighten a smile better than a few well-placed caps, crowns or cosmetic dental procedures. And nothing will turn the smile into a frown quicker than an unexpected bill for the related work.

Unless your benefits plan includes major dental coverage, cosmetic options such as caps, crowns and braces are rarely covered.

5. Make the toll-free call for valuable details

Many benefits plans come complete with a toll-free telephone number that can be called to ask any related questions. Some insurers even offer online tools that can be used to see exactly when the last claim was submitted, and any available dollars that remain.

6. Dont delay the paperwork, and offer as many details as you can

Claims are often denied because of nothing more than a lack of information. That means forms need to include every required detail, whether it is an eight-digit Drug Identification Number (DIN), policy number, dollar amount or date.

The timing of the paperwork can make a difference of its own. It can take 120 days to process a Long Term Disability claim after it is received, and that can seem like a lifetime for an injured employee who has no other way to pay a rent cheque.

7. Know the limits to disability payments

As valuable as disability payments can be, there are often limits in place. Under what's known as an "own-occupational" requirement, an insurer might cover Long Term Disability payments for two years, but then look to see if the injured or sick employee is qualified or capable to perform any other work.

8. Think of your benefits consultant as an advocate

The struggle to overturn a denied claim can seem like a daunting task - particularly if it looks like a claim should have been covered in the first place.

That's where a skilled benefits consultant helps.

Employees, for example, can turn to the benefits consultant if they are reluctant to share health problems with employers.

The calls are not limited to fighting denied claims, either. Employers might want to confidentially share information about someone who is abusing a benefits plan - such as an employee who is off work because of an injured shoulder, even though they have been seen building a backyard deck. Armed with information like that, an insurer may ask the plan holder to fill out a more detailed form to prove the nature of the injury, or complete a "functionability" test to ensure a payment is deserved.

After all, benefits are designed to protect the employees who need them most.

Is there a topic that you would like me to address in a future edition of the Buzz? A burning question about benefits plans that has always been hanging over your head? Let me know. Drop a quick email to billz@callerygroup.com.

Top Tips:

  • Review the Explanation of Benefits (EOB) carefully. If a claim is denied, this document will pinpoint what went wrong. Many issues can be addressed by supplying missing information.
  • Check to see if limits are based on a calendar year or a rolling calendar. The maximum payouts for vision care are often based on a 24-month rolling calendar. When limits are reached mid-way through the year, other claims can be denied for the next 730 days.
  • Follow all the required steps when claiming orthotic shoes. Any claims will need to be backed by specialists like a chiropodist and supported with a gait test. The shoes will also need to be customized.

Copyright Notice

All rights reserved. All of the content herein is the sole property of the Callery Group, and may not be reproduced, transmitted, or stored in a retrieval system - in whole or in part - without the written permission of the Callery Group. Links to the originating article at www.callerygroup.com are permitted.

The Buzz Bits
Miscellaneous links to interesting benefits information

Three benefits must-haves for Generation Y: Benefits Canada

Three reasons why SMEs must address workplace mental health: smallbizadvisorr

No international licence necessary in Florida: smallbizadvisor

The headache of late applicants: smallbizadvisor

Community Ethics, Big City Expertise

Subscribe to the Buzz Blog

Blog archive

Time To Get Ahead Of The Curve

"We've all been working from home for the last four months and now it looks like we're probably never going to go back to working in the office." It’s a statement I'm hearing every day, as more and more workplaces are discovering that working from home is working out better than anyone ever imagined. [more]

Hitting Reset On The Mindset

We can't afford to think "when this is over." We have a job to do and a chance to step up and really shine [more]

Working From Home

10 ways to communicate effectively in a working-from-home environment  [more]

Managing Paramedical Benefits

Think aboutwhy you offer paramedical benefits in order to manage them effectively  [more]

It's All About The Experience

I thought cell phone dependency was a cliche - until I lost mine far from home  [more]

What Happened When I Lost My Phone

I thought cell phone dependency was a cliche - until I lost mine far from home  [more]

"Mental Health" Doesn't Mean What it Used to Mean

We’re done admiring the problem, and it’s time to take some action  [more]

When There is No Return to Work

An Ontario court has set a limit on employers' return-to-work obligations  [more]

Rooting Out the Root Causes

When benefits fraud gets out of hand, it's a sign of big problems higher up  [more]

Four Key Gaps in Benefits Plans

Annual Sanofi survey zeros in on knowledge gaps in plan management [more]

How to Avoid Falling Through the Generation Gaps

Never mind "the older" and "the younger" generation – there are now five of them [more]

Predictive Analysis and Three Other Trends to Watch

Benefits and wellness programs are never going to be the same again [more]

Pharmacare: A Solution Looking for a Problem

Pharmacare would be such a good idea - if everybody wasn't already covered [more]

When the "Human Side" Gets Right in Your Face

A seriously injured client gives us a whole new perspective on resilience [more]

Is Virtual Health Care the New Must-Have Benefit?

In the age of the smart phone, do we really still need to line up and wait to talk to a doctor? [more]

Three Things I Learned from Doc Martin

When it comes to losing weight, there are a few basics you just can't get around [more]

Top 10 Take-Aways from a Crazy Busy Year

What we can learn from the biggest and most controversial issues we've looked at this year [more]

Engagement is the New Normal

What do employees really want from their jobs? [more]

10 Things You Need to Know about Travel Insurance

How to avoid making the mistakes that could cost you your insurance coverage [more]

How to Give First Aid for Mental Health

There's a new perspective on mental health at work, and it's a real eye-opener [more]

What Else Is In Bill 148 - And Why You Need to Know

There's a lot more to Bill 148 than minimum wage hikes and personal emergency leave [more]

The Next Big Thing in Benefits?

Major insurance providers are looking seriously at covering pharmacogenetic testing [more]

Will Cannabis Legalization Change Attitudes about Testing?

New legal limits for impairment may have a bigger impact than legalization [more]

Avoiding The Dreaded "Claim Rejected"

Benefits administrators are always caught in the middle when claims are rejected [more]

Big Data Takes On Benefits Fraud

Data analysis is starting to make a dent in many benefits fraud schemes [more]

The Chronic Pain Puzzle

Financial costs alone are higher than cancer, heart disease and HIV combined [more]

Financial Wellness: Why Money Management Counseling is Such a Good Idea

Debt counseling and money management education can make a big difference for employees [more]

The Next Big Thing: Mental Health Policy

It's time to get ahead of the curve on this one [more]

Unintended Lessons I've learned about Blogging so far

You never know what's going to happen when you click on a link [more]

Drugs, Alcohol and, Oh Yes, Marijuana

Changing times may require all of us to take a long hard look at our drug-and-alcohol policies [more]

Best Tips For Sleeping Well

If you're just not sleeping well, there are some pretty effective things you can do to make it better [more]

Survey Says: Wellness Programs Improve Overall Satisfaction

It seems that employees' satisfaction with wellness programs spills over into satisfaction with their benefits programs and their jobs in general [more]

Changes Coming to Personal Emergency Leave Laws

Amendments to the Employment Standards Act will significantly increase legally mandated employee leaves [more]

The Good News and the Bad News on Diabetes

We keep hearing about a "diabetes epidemic," but there are things we can do now to improve our odds of beating the statistics [more]

Who's Your "Broker" Working For?

In a world of brokers, agents, advisors and consultants, it's important to stay focused on who's really working for you [more]

The Secret to Really Good Workplace Wellness

Workplace wellness is a way to solve a lot of problems before they even come up [more]

Medical Marijuana - More Questions than Answers

A lack of medical consensus makes drug plan coverage of medical marijuana very difficult [more]

Pharmacogenomics Means Better Prescriptions

A simple DNA test can now help pinpoint which drugs are going to work best for you [more]

Why Airplanes Crash

What one successful CEO learned from air crash investigations – and how it all applies to managing any organization [more]

Not A Delicate Subject Anymore...

How to start the conversation about mental health in the workplace [more]

A Look Inside

There's more to this business that we usually talk about... [more]

Bio What-Now?

Get ready for "generic" biologics. [more]

What You Don't Want to Say to Your Doctor

There are some things that you want to explain to your doctor, and some things you really should stay away from. [more]

Your Dentist's Pet Peeve

Why you should know all the ins and outs of your dental insurance plan before you ever lean back in the chair and open wide [more]

About that Credit Card Travel Insurance

It may be of some value, especially if you have no pre-existing conditions, but you really need to read that fine print [more]

Right Drug, Right Time, Right Cost

Why you should work with your doctor, your pharmacist, and your drug plan to make sure you get optimal treatmenty [more]

Big Smiles

A focus on dental plans will ensure that everyone remains happy [more]

Your Doctor Doesn't Know Everything

When it comes to prescriptions, patients need to be part of the conversation [more]

Prescription for Disaster

Advances in pharmaceuticals are threatening your drug plan [more]

Sleep Easy

Conditions like sleep apnea can be treated, ensuring proper rest and productive days [more]

Easy as EAP

Formal support makes a big difference when employees face personal challenges [more]

Well Done

10 ways to develop an effective workplace wellness program [more]

Mind Matters

Businesses can't afford to ignore the mental health of their employees [more]

Brian's Story

Brian Callery is celebrating 40 years in our business. It's a commitment that makes a difference in his clients' businesses [more]

The Benefits to You

The same plans designed to protect employees will also offer advantages to employers [more]

Lawyer Up

There are legal ramifications around changing benefit plans - especially if an employee is being terminated [more]

Travel Trauma

Dream vacations can turn into nightmares when travel insurance claims are denied [more]

Evolution Solution

Evolving benefit plans will meet employee needs and support recruiting and retention efforts [more]

Plan & Predict

How rising paramedical claims, drug reforms, and other trends will affect your workplace benefits [more]

Who Benefits

Education makes the case for workplace benefit plans [more]

Season of Renewal

Important questions to ask your benefits advisor before inking a deal [more]

Preventive Measures

Paramedical services help keep employees healthy, on the job, and productive [more]

A Bounce in Their Step

Canada Rubber Group employees are embracing their new wellness program [more]

Business Benefits

Shandex Group and Indaco Manufacturing discuss the value of evolving employee benefits plans [more]

A New Mindset

Workplaces can't afford to ignore the mental health of employees [more]

Cost Cutters

10 cost-cutting strategies to protect your benefits plan [more]

Safe Travels

12 ways to protect yourself on your next vacation [more]

Breaking News

Learn from the mistakes of an AOL executive when discussing any changes to your benefits plans [more]

Watch the Gaps

Protect against turnover and lost opportunities by recognizing the generation gaps [more]

Generation Next

Generation Y represents the future of your business - and will see workplace benefits plans in a different way [more]

Absent Minded

Employers are paying the price for absenteeism, but it can be controlled [more]

Think Positive

Programs that build positive workplaces make business sense [more]

Back to School

8 important lessons your employees need to learn about benefits plans [more]

Find a Better Broker

6 questions you should ask anyone who wants to sell you a benefits plan [more]

Plan Your ROI

5 ways employee benefits plans can deliver a real Return on Investment [more]

The Benefit of Benefits

3 ways a benefits plan can improve your company's bottom line. [more]

A Healthy Dose of Information

5 questions for your pharmacist that might save your drug plan and your wallet. [more]

Claim Denied

Consider these 8 ways to avoid rejected benefit claims. [more]

Travel Planning

6 questions to ask before assuming you are protected by a group plan's travel insurance. [more]

Biologic Logic

Growing list of biologic drugs could bankrupt poorly protected drug plans. [more]

Smart Shopping

8 shopping habits that will protect your benefits plan. [more]

Tough Medicine

Employees will share more responsibilities and higher costs to sustain their benefits. [more]

Crime Costs

5 scams that could be placing your benefits plan at risk. [more]

A Prescription for Your Drug Plan

Skyrocketing drug prices may be threatening your benefits plan, but generic drugs offer a cure. [more]

Planes, Trains and Travel Insurance

The fine print in your travel insurance may leave you more exposed than you think. [more]

Healthy and Wealthy

5 steps to an employee wellness program that will generate real financial returns. [more]

Avoiding Burnout During Holiday Season

Education and Prevention can help control spiraling benefit costs. [more]

Sweat the Small Stuff

Protect your staff by avoiding these common "paperwork" mistakes by administrators. [more]

Services Personal Services Corporate Services