Denial of Claims

Denial of claims associated with a research study presents a challenge.

The best plan to avoid denials is to be pro-active before the research study begins.  The PI and study team should: 

  • Obtain sponsor coverage for sponsor-required services and subject injury whenever possible as part of the budget negotiation.
  • Ensure all applicable pre-approvals are in place prior any subject enrollment taking place.
  • Assist participants in contacting a UF Health Financial Representative to help navigate the insurance pre-approval process.
  • Make sure the Informed Consent Form (ICF) outlines the billing plan.
  • Review the individual participant’s financial or payment source options.
  • Follow the study billing plan when services are ordered and claims are filed for reimbursement.

Once a research study claim or service has been denied there should be an inquiry or appeal to ensure the billable services were submitted correctly, and the provision of a detailed medical explanation to the insurance company medical director may be warranted.  The inquiry or appeal requires an active effort involving the PI, study team, Shands PFS, UFHP, and/or other providers of study related claims or services so that the denial can be resolved in a positive and timely fashion to the benefit of all, including the participant, hospital and department. The study participant should not be billed if an institutional error caused the denied claim.

As a final step, it may be appropriate to ascertain what documented pre-approval procedures were followed and evaluate any errors found so that denials of claims and services are avoided in the future.

Questions?