Those in the know always talk about claims that are “targeted” without letting insureds know how they can tell. “Targeted”, in a general sense, means that claims are identified, using internal criteria, to be aggressively risk managed with the objective of denying the claim. While this is MY definition of “targeted”, I think it is a good one.
Before I begin let me say that “targeting” claims for denial is an egregious, unfair claims practice. Then again, insurance companies rarely do what they are supposed to do, namely reviewing claims in “good faith and fair dealing.” “Targeting claims” isn’t supposed to happen.
Here are the evidences of whether or not your claim has been targeted for denial:
- Time periods. Claims are predominately targeted after the 15th of each month, at the end of a Quarter (March, June, September, and December) year-end. Year-end targeting usually begins in October for year-end profitability results.
- Your insurer will begin asking for patient notes, forms to be filled out, outside of the normal time period when you usually provide an update. For example, if your normal updates happen in January, but you receive an update request in February, I’d be suspicious for a March denial. Update requests outside of the normal time period are indications of “targeting.”
- Your doctor notifies you that he/she is receiving multiple requests to fill out forms and provide patient notes, so much so your doctor is getting upset.
- Your doctor informs you that an insurance doc wants to have a phone conversation.
- You see that you are being surveilled and followed.
- Your claims handler wants to do a phone interview with you, supposedly to “update” your claim.
- ERISA timelines are violated, mostly extended so that insurers can conduct surveillance and have enough time to do it.
- Requests for Independent Medical Evaluations suddenly come up, but watch the timeline. If you’ve asked to do an IME in October, for example, your claim is targeted for denial by December.
- Evidences of citing multiple internal medical reviews indicates your insurer is stacking the deck with documented medical reviews.
- Evidences of “any occupation” reviews suddenly being done years after the two-year period has gone by.
- Not being able to get in touch with a claims handler for a week or more.
While this is a short list of “target indicators”, it is by no means all inclusive. Insurance companies budget future profits and they do it with the help of targeting claims. Be watchful and aware if you experience the above, and/or anything unusual is noticed during the time periods I described. Get help if you need to manage your insurer’s “stacking the deck” activities.
