Denial of a health insurance claim can put a family in a financial bind. It may prevent their ability to receive and pay for proper medical care, afford groceries, and simply take care of day-to-day needs.
Dealing with insurance companies after they have denied a claim can be a lengthy process and the source of many headaches. Insurance companies have lawyers who will use every resource to avoid overturning the denied claim.
Fortunately, you also have a resource at your disposal. Timberlake and League is available to advocate on your behalf. We go head-to-head with health insurance companies in the event you need us. Here, we will provide a guide to disputing denied health insurance claims.
Reasons a Claim May be Denied
Incorrect diagnosis codes and incorrectly entering your policy number are common reasons your claim can be denied. Simply correcting that information should get your claim approved and reduce denials by 34%.
The following reasons present a bigger challenge for approval:
- Missing the filing deadline for a claim
- The service authorization period expired
- Your insurance plan excluded the procedure or service
- The insurance provider identified the medical procedure or service as not medically necessary
In these instances, the first thing you should do is file an appeal.
Filing an Appeal: Internal Review vs. External Review
HealthCare.gov shows that, of the 230 million in-network claims in their individual health plans, 42.3 million claims were denied in 2020. Patients appealed less than one percent of those denials. Alabama insurers reporting to HealthCare.gov have a denial rate of 22%.
You have and should exercise your right to appeal a denial. There are two ways:
- Internal Review – When your claim is denied, or health insurance coverage canceled, you can ask your insurance provider to conduct a fair review of its decision. Health insurance companies usually overturn internally reviewed claim denials 40% of the time.
- External Review – An external review means a party outside the insurance provider reviews the appeal. When an independent third party reviews a denial, the insurance company no longer has the final say over whether to pay the claim.
Preventing Future Insurance Claim Denials
Thirty percent (30%) of claims get denied on the initial submission. These are key factors in avoiding future denials:
- Secure pre-approval for all necessary medical procedures. HealthCare.gov reports that nine percent of their denials in 2020 were due to non-referral or no preauthorization.
- Know what your insurance will and will not cover. Eighteen percent (18%) of claims are denied because the insurance plan did not cover the service.
- Learn the appeals process. Knowledge is power and can give you leverage to get your claim approved.
Paying insurance premiums provides peace of mind that there is a plan to take care of an issue should something happen. Yet, you are left paying the tab when the insurance company does not uphold its end of the bargain. Fortunately, that does not mean you are out of options. Hiring a lawyer can help get the denial reversed, so you can get all the benefits you deserve.
If a tragedy has left you devastated and you’re now being forced to deal with your health insurance company denying a claim, please get in touch with the experienced attorneys at Timberlake & League. We will fight to get your denied claim overturned.