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CODING & BILLING
profits. Now, because of the Affordable Care Act (ACA), they must spend a specific percentage of their premiums on claims and activities to improve health care. Otherwise, they have to pay rebates. How does this affect you? Because their goal is to maximize profits, insurers look for other ways to increase earnings. One way to recover from unexpected losses is to increase denials and make unreasonable payment demands.
2 Insurance companies are required by law to pay claims.
There's an implied covenant of good faith in every insurance contract. State and federal laws require that denials be based on facts, not speculation. If you know the rules, you can address attempts by payors to skirt laws, or use only portions of laws, to justify denials. Something else to watch out for: Payors sometimes justify denials by citing one state law, even though another state or federal law — one that supports a claim — is more applicable.
3 Insurance companies must act in good faith in interpreting policies and investigating and paying claims.
They cannot use deceptive business practices to delay, deny or underpay. They're obligated to act in good faith on behalf of their policyholders.
4 Insurance companies must keep detailed records of all claims activities, and make them available.
An insurer that denies a claim must promptly explain the facts and/or the law it relied on. You have a right to review all data used to make
the determination.
