When your claim is denied, or your insurance provider doesn't approve the care you need, you may believe there's nothing you can do. That's not true at all.
You will learn about the most popular reasons why health insurance provides issue denials, from paperwork mistakes to cost-cutting methods. You will also learn in detail the process to fight health insurance denial and the steps you can take if your appeal does fail.
To fight a health insurance denial, you need to ensure you are calm when making your argument either by mail or via telephone, keep up with the appeal deadlines and submit the required documentation to prove your case. Involve your primary care doctor and write an appeal letter as well.
The information in this article has been collated using trustworthy sources to ensure that every statement written is accurate at the time of publishing. The process we highlight to fight health insurance denial must be credible as incorrect information could prove harmful. To that end, sources including Healthcare.gov, various health insurance companies, patient advocacy groups, and health insurance industry experts were used.
Why Do Health Insurance Companies Issue Denials?
There are hundreds if not thousands of reasons why a health insurance company would issue a denial for a service. Most of the reasons are basic and can be easily fixed. However, others are a bit more complicated.
The most widespread reason behind denials include:
A Means Of Cutting Costs
This happens when your health insurance provider wants to put forward a different and less expensive treatment first. In such a case, the less expensive treatment is usually approved first.
It could also be that you provided insufficient information with the pre-authorization or claim request. For instance, if you requested an MRI for your arm and your doctor didn't send information concerning your arm.
Issues With In-Network Providers
Depending on how your health insurance policy is structured, you could only be covered for services provided by facilities and doctors within your health insurance policy's network.
Going outside the network, in this case, could cause your insurance provider to deny your claim. If you are trying to gain authorization for a non-network healthcare provider to perform a service, your insurer could deny authorization.
They, however, reconsider if you select another healthcare provider. You could also try convincing your policy provider that the medical provider is the only capable one to provide the service.
In a situation like that, an exception could be made. You should be aware that you might have to make up the difference between what your chosen provider charges and what your health insurance company pays.
If Your Health Insurance Plan Doesn't Cover The Service
This happens when your coverage doesn't extend to the requested treatment. This is very common with services that aren't FDA approved or cosmetic surgery. It can also be prevalent with healthcare services that don't meet your state's description of ACA's essential healthcare benefits.
If you have a small group or individual market plan, this could include chiropractic and acupuncture services.
You should note that if your plan was obtained as a large group policy or you are self-employed, the ACA's essential health benefits will not be mandated to cover such services. Ensure you check your policy details to know what's covered and what isn't.
You could have significant coverage gaps if you bought a plan that isn't ACA-complaint. This could be a fixed indemnity policy or a short-term plan. These plans do not provide the expected coverage for things such as maternity care, mental health care, prescription drugs, and more.
This happens when your health insurance provider doesn't believe the healthcare service in question is necessary. There are two reasons for this:
- It could be that your health insurance provider doesn't believe the service is necessary even though you need it. You might need your doctor to provide additional information concerning the requested healthcare service and why you need it
- You don't need the service
For instance, if your health insurance provider has your name listed as Jon Smith and your doctor's office submits a claim for John Smith. It could also be that the claim was submitted with an incurred billing code.
These are just a few of the reasons why your health insurance provider would deny your claim.
Process To Fight Health Insurance Denial
Every health insurance plan comes with a process to appeal. You should note that an appeal is a challenging prospect. This is especially true for individuals that don't have a medical background.
The process to fight health insurance denial takes time and effort; however, it is worth it. Research shows that 66% of appeals are successful. There are essential things to remember when attempting an appeal:
You Have To Remain Calm
The impact of having to pay a substantial health expense that could cause people to lose their houses or destroy their credit can be quite overwhelming. It is even strong enough to cause people to become irrational.
Your aim should be to prove to your insurance company that they are contractually required to pay for that service. It is not about you highlighting the hardship such a large bill could cause.
This is why you need to fully concentrate on the appropriate and necessary steps in your appeal process, rather than letting your emotions lead you.
Make Your Argument
You have to concentrate on presenting an argument built on facts. To bolster your odds of winning your appeal, begin as soon as you get your denial or the bill. Most people tend to start the appeal process sometime after the bill has been sent to a collection agency.
If your issue is due to a statement error, which is a popular reason for denials, call your health insurance provider. Find out the fastest way to solve this.
It could be the mismatched medical records or missing billing codes that are the reason for your denial. Calling them to find out the issue can help you resolve your health insurance denial.
If the problem isn't a quick fix, you should carefully inspect the denial. The ACA mandates all health insurance providers issue a written denial complete with clear deadlines and an explanation. This can be your guide moving forward.
There are numerous appeal levels. The first is called reconsideration. It typically involves a peer review between your primary care physician and a physician at your health insurance company. It's your decision to begin with this appeal level.
Should you be unsuccessful, an internal appeal would be the next step. A medical director would review your case. Should this also be denied, the last appeal level would be an external review using an independent board-certified doctor.
During the entire appeal process, you must be organized. One of the mistakes people make with these appeals deal with the requirements and the deadlines.
Ensure that every call is documented and every document pertaining to your issue is stored. Keep a timeline of every event, whether big or small, phone calls made, the people you spoke to, and when you spoke to them.
You should also write the appeal deadline downs, ticking them off as you meet them.
Write Your Appeal Letter
Should your calls not be effective, you will have to write a letter that carefully explains why you believe the denial is incorrect.
Your letter should include documentation like case notes from your doctor, details on your knowledge of your coverage, and test results. You can add information from industry experts to provide more weight to your argument.
In your letter, briefly describe your health condition and its impact on your life. Ensure you are brief and pleasant. Also, avoid sounding threatening or highlighting your frustration. You can ask your primary care doctor to review the letter, making revisions where necessary.
To add additional weight, your doctor could also submit their letter. Ensure everything you send is by certified mail and request a return receipt.
If your primary care doctor, for some reason, chooses not to cooperate, you can use it in your defense and against them. Highlight any errors you believe your physician made to cause your denial.
Considering appeals can be technical, you might want to request additional help. There are patient advocacy groups that offer free or low-cost appeal assistance to patients that have been diagnosed with chronic, debilitating, or life-threatening diseases.
You could also hire professional patient advocacy firms. Their services typically cost anything from $100 to $350 for the initial review.
What To Do If Your Appeal Fails
When both internal and external appeals can overturn your health insurance provider's decision, there are other options you can select.
You can request assistance from your doctor or the hospital. Should all else fail, you can consider employing the services of a lawyer. This, of course, would incur additional expenses. However, if your health insurance denial translates into huge costs, having a lawyer can be worth it.