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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. Donít 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.

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