What are the five guidelines of good claims practices for claims examiners?

Question

What will be an ideal response?

Answer 1

Answer:
a. Fully analyze the claim initially. Consider all possible reasons for acceptance or denial. Look for a way to pay a claim, not deny it. Often an initial review of a claim will reveal clear and obvious grounds for denial. Sometimes the obvious grounds disappear later when the denial is questioned. Always clearly document the grounds for denial. Resist the natural temptation to deny a claim without a complete investigation and without considering all other possible grounds for acceptance. Keep in mind that for health plan years beginning on or after September 23, 2010, the Affordable Care Act of 2010 makes it illegal for insurance companies to rescind coverage based on an error or technicality.
b. Thoroughly investigate and document the facts within the claim file. This may be one of the most important steps that each examiner needs to take before paying or denying a claim. The lack of a proper investigation or documentation has probably resulted in more bad faith lawsuits than any other individual factor.
c. Handle claims promptly and keep claimants informed.
1. Give priority to delayed/pended claims.
2. Resolve conflicting evidence or information promptly.
3. Do not withhold or delay payments in hope of a compromise.
4. Be sure to indicate the date and other documentation for the following: when claims are received or processed, when correspondence is received or sent, and when telephone calls are received or made.
d. Make proper use of medical evidence.
1. Always contact the doctor to clear up any medical questions concerning the claimant.
2. When a second medical opinion is required, the proper selection of an independent medical examiner is very important. A specialist should be chosen for the specific disease or injury. The specialist must always be provided with all the claimant's relevant medical information and records, whether they are favorable or unfavorable. Also, the examiner cannot provide a correct conclusion unless the correct questions are asked. Sometimes asking the correct questions is the most difficult part of preparing a case for review.
e. Be observant in looking for excessive charges. There may be providers who indicate a long list of diagnoses to match the wide variety of tests given, so that the claim will be covered by the insurance carrier.