Why is this claim denied…


I work for one of the larger health insurance companies in the US and used to take inbound calls from providers. What it really was though was just a bunch of other call centers calling us to ask remedial questions about the claims that the billers at the hospital couldn’t be bothered to look up themselves. I’m talking really basic stuff, like did the claim pay or deny, and mind you the providers received all this info from us already but couldn’t be bothered to actually look at it. So they wasted all this money contracting with companies to call for them. Anyway, I digress. So I get one of the usual very basic calls and it goes something like this:

Provider: why is this claim denied?

Me: the claim denied because the provider is out of network.

Provider: why is that?

Me: well it appears that the provider is out of network with the member’s plan.

Provider: I don’t understand.

I do not miss that job at all.

Edit: this happened a couple years ago and I was just reminded of it.


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Karen supplier wants to talk to the manager

Do you REALLY work there?