10 Steps To Take If Your Health Insurance Company Denies Coverage
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Nearly 17% of in-network claims were denied in 2021. Of in-network claims, about 14% were denied because the claim was for an excluded service, 8% due to lack of preauthorization or referral, and only about 2% based on medical necessity.  Dealing with an insurance denial can be a frustrating and emotionally draining experience. However, armed with knowledge, persistence, and the right resources, you can take proactive steps to challenge the denial and secure the coverage you need for your treatment. Remember that you have the right to appeal and advocate for your health and well-being.
If you received a notice of denial from your health insurance company regarding coverage for a necessary medical treatment, remember that denials are not final. Understanding your policy is important and so is writing a persuasive appeal, seeking help and staying persistent.
When you receive the denial letter, it should include information on how to initiate the appeal process along with details about any meetings or reviews that may be part of the process. It's important to stay organized as you follow the insurer's instructions.
Let's explore each of 10 steps you need to take when your insurance company denies coverage for treatment.
1. Review Your Policy
The first step when you receive a denial is to carefully review your insurance policy. Understanding the terms and conditions, coverage limits, deductibles and exclusions outlined in your policy can provide insights into the reasons for the denial. Mistakes do happen but sometimes we misunderstand how the type of coverage we have works. For instance, if you have a PPO plan, not an HMO, you may have to pay for costs out of pocket until you reach your deductible.
2. Contact Your Insurance Provider
Reach out to your insurance provider if you’re confused or strongly feel that there’s been a mistake. Sometimes, denials can result from administrative errors or a misunderstanding. Ask for detailed information about the denial and have the letter handy. This initial contact can help you gather essential information for your appeal or they may clarify why your treatment wasn’t covered.
3. Gather Supporting Documents
Compile all relevant documents to support your case if you’re sure that according to the terms and conditions of your policy that you should have coverage for the treatment. This may include medical records, treatment plans, notes from healthcare providers and any other correspondence related to the treatment. Having a comprehensive file of documentation will strengthen your appeal.
4. Understand the Appeal Process
Most insurance companies have an appeal process in place for denied claims. Familiarize yourself with this process, including deadlines for submission and the required forms. Typically, the appeal process involves submitting a formal request for reconsideration and providing additional evidence to support your claim.
The format of appeal meetings during the insurance appeals process can vary depending on several factors, including the insurance company's policies, the nature of the denial, and the specific circumstances of the case. Here are the most common formats:
- Written Appeal: In many cases, the appeal process begins with a written appeal. This involves submitting a formal appeal letter or form, along with supporting documentation, to the insurance company. The insurance company reviews the written appeal and documents without the need for an in-person or virtual meeting.
- Phone Review: Some insurance companies conduct appeal reviews over the phone. During a phone review, you may have the opportunity to discuss your case with a representative from the insurance company. This allows you to present your arguments, provide additional information and address any questions they may have.
- Virtual Meetings: With the increasing use of virtual communications, some insurance companies may conduct appeal meetings through video conferencing. T
- In-Person Meetings: In rare cases, an insurance company may offer an in-person meeting as part of the appeal process. This typically occurs for complex cases or when there is a need for face-to-face discussions.
5. Write a Strong Appeal Letter
The appeals process usually begins with the insured writing an appeal letter, which should convincingly outline the reasons why your treatment should be covered. Be clear, concise and factual in the letter.
6. Seek Outside Assistance
Consider enlisting the help of professionals experienced in insurance appeals, such as patient advocates or legal experts specializing in healthcare. They can offer guidance, review your case, and assist in constructing a compelling appeal.
Here are some other types of professions you may want to contact for help:
- Medical Billing Specialists: These experts specialize in medical billing and coding. They can review your medical bills, ensure that they are accurately coded and identify any errors that might have contributed to the denial.
- Healthcare Consultants: Consultants have a deep understanding of the healthcare system, insurance industry and medical practices. They can help you navigate the complexities of the appeals process, provide insights into regulations and offer strategies to win.
- Independent Medical Reviewers: Physicians or medical professionals can evaluate the medical necessity of a denied treatment. Their expert opinion can carry significant weight in an appeal, especially when challenging a denial based on medical reasons.
- Public Adjusters: Public adjusters are professionals who specialize in insurance claims. Some public adjusters have expertise in health insurance appeals. They can assist in documenting your case, negotiating with the insurance company and advocating for coverage.
- Healthcare Attorneys: It may be beneficial to consult with an attorney who specializes in healthcare law if the bill is heavy and the case is complex. Healthcare attorneys can provide legal expertise, take part in negotiations or hearings and ensure that your rights are protected.
- Patient Advocates: In addition to legal experts, patient advocates are professionals who specialize in helping patients navigate the healthcare system and insurance challenges. They can provide support, guidance, and assistance in preparing and presenting your case during the appeal process.
- Case Managers: Some healthcare facilities employ case managers who can assist with insurance appeals. Case managers are knowledgeable about the medical aspects of a case and can work with insurance companies on your behalf to ensure that necessary treatments are covered.
- Healthcare Compliance Specialists: These professionals specialize in healthcare compliance and regulations. They can help ensure that your treatment meets the necessary regulatory standards and assist in making a case for coverage based on compliance with healthcare laws.
- Insurance Brokers and Agents: Contact the agent who sold you the policy. They may have experience in dealing with insurance appeals or can point you to the right person.
7. Escalate the Appeal If Necessary
If your initial appeal is denied, don't lose hope. Many insurance companies have multiple levels of appeal. Escalate your case to the next level, which may involve an independent review or arbitration. Try to find more strong supporting evidence if you can.
8. Explore External Resources
Contact your state's insurance department for guidance on navigating insurance denials. Additionally, if your policy is subject to federal laws like the Affordable Care Act (ACA), you may have further avenues for appeal under federal regulations.
9. Consider Negotiation
Insurance providers may be willing to negotiate a compromise. Contact the insurer to explore alternative solutions, such as partial coverage or a payment plan.
10. Stay Persistent
Persistence and a thorough understanding of your policy can significantly increase your chances of getting coverage for necessary treatment.
If you find that you’re left in a lurch after the process is over, you may want to consider switching your health insurance company. If you have an employer sponsored health plan, it may even be more costly than buying a solid individual or family plan on the market. It’s important to consider coverage, premiums and all out-of-pocket costs when comparing plans. You can start by entering your zip code on this page.