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Insurance Denies a Medical Claim

What If My Insurance Denies a Medical Claim?

Given the high costs of medical insurance, it becomes very frustrating to learn that a certain treatment or medication is denied by your provider, or requires prior authorization before full (or partial) coverage kicks in. 

If you feel like you’re constantly battling with your health insurance to have it cover costs related to medical testing, procedures, or certain medications, you’re certainly not alone.

Having said that, if you’re undergoing treatment or recovering from an injury, surgery, or illness, it can feel even more overwhelming to fight this battle, in addition to coping with your own injury or illness.

The good news is you do have options! If your insurance company refuses to pay a claim, or does not pay their full portion of it, you may have legal grounds to file an appeal. 

Why Would Insurance Deny a Claim?

Before we discuss the appeal process, let’s first review a few common reasons why a provider may refuse to cover a medical-related expense.

Medical Necessity

Often, claims are denied based on “medical necessity.” The insurance company reviews a procedure and decides that it was not medically necessary, even though your doctor or surgeon recommended the treatment. 

If this happens to you, you can ask your health care provider to write a written response. This should state why he or she felt the procedure or test was medically necessary. If a formal appeal is necessary, having a health care provider who is willing to help you is invaluable.

Generic Available

Another reason for insurance denials, especially for certain medications, is your clinician may prescribe a brand-name medication when a generic (less expensive) option is available. Again, depending on your individual situation, your clinician may want you to take the brand-name medication over the generic prescription, which means he or she will need to provide additional information to the insurer. 

In some cases, an insurer may pay for the brand-name prescription after the patient has tried the generic brand with little-to-no success.

Not Covered By Policy

Of course, there is the possibility that your policy simply does not cover certain procedures or medications, or requires you to pay out-of-pocket until you reach a deductible. 

Missing Information

People make mistakes, even healthcare teams. So, during the reimbursement claim process, an individual may enter inaccurate patient details, or leave key information out that your insurance may need to cover your medical expense.

What Happens When Insurance Denies a Medical Claim?

If your claim is denied, you have three options:

  1. Accept their decision and pay out-of-pocket.
  2. Choose to not receive your prescribed treatment/medication.
  3. Request information on why the claim was denied. And if you disagree with the decision, you may qualify to file an appeal

What Can You Do When Insurance Company Refuses To Pay

In the event that you do not agree with the insurance denial, there are a few essential steps you’ll want to take before filing an appeal.

Get Pre-Authorization, If Possible

If you need to have surgery, or an elective procedure, make sure your doctor or hospital gets pre-authorization from your insurance company first. Most doctors or hospitals will be happy to provide you with a copy of the pre-authorization. 

If the insurance company issues a pre-authorization, they are more likely to pay.

Understand the Benefits of Your Policy

As noted earlier, sometimes a medical claim is denied because it is not covered under your policy. 

Therefore, it’s important to review your health insurance policy to find out what it does and does not cover. Know this information in advance, especially if you’re required to go to a specific hospital for referrals. And remember to learn which tests or procedures need a pre-authorization. 

You should also be aware of your deductible and your maximum out-of-pocket expenses.

Taking the time to read your policy, and noting important information, can help you make the right decision about your medical care. If your insurance favors one hospital system, for example, you’ll want to know that before you are faced with an emergency situation. 

Keep All Copies of EOBs and Medical bills

Once they receive a claim, the law requires insurers to provide you with an explanation of benefits (EOB). This details the claim they received, and the amount they intend to pay. 

The EOB contains important information, such as 

  • Details about the service provided
  • How much the bill was
  • What part the insurance company covers

If you disagree with something on the EOB, or don’t understand it, call your insurance company immediately. 

Often, a phone call is all it takes to get your insurance carrier to pay their part of the claim. Ask to speak to a customer service agent. Next, have him or  her explain why the provider is not paying the claim in full. 

Take notes during your conversation and ask for the name or identification number of the person you are speaking with. If you do not agree with the final decision about a claim, you may qualify to file an appeal.

Just remember that although everyone’s situation will differ, the most important thing to do is be patient, keep records, and stay organized, as this may help increase the chances of getting the claim paid.

How to File an Appeal

If you are not satisfied that your insurance company is paying what they should, you should appeal. Don’t assume the insurer is correct. 

In fact, some insurance companies are aggressive about denying claims. They assume a percentage of their customers will not bother with the appeals process. Your policy and your EOB should tell you how to file an appeal. 

File On Time

Appeals are time-sensitive, so make sure you know how long you have to file. The initial step in filing an appeal is usually straightforward, so make sure you file it on time.

Keep Records Organized

Collect your documentation, such as your medical records and letters from your providers, and send them to the insurer. If the appeal is denied, you can then ask for a full review of your case. 

At that point, an insurance company will normally have a physician review the coverage decision and decide if the policy covers the treatment or test.

Get Support

Contact your state’s insurance department for assistance in filing an appeal. Use the resources provided by your state and do not be afraid to also ask for assistance from your health care provider. After all, they want to receive payment. So, it is in their interest to assist you in obtaining coverage for the claim. 

Don’t Give Up

It may take several rounds of appeals before a favorable coverage decision is made.  

Seek Legal Counsel for a Medical Claim, If Needed

Since 1883, the attorneys at Doar, Drill & Skow have represented families, individuals and businesses across Wisconsin and Minnesota in practice areas that include personal injury, workers compensation, medical malpractice, and more. 

We are one of western Wisconsin’s most skilled and successful personal injury law firms. We’ve built our reputation on what we achieve for our clients. We want to be your advocate and help you find justice, regardless of your circumstances. 

To learn more about how we can help, contact us today for a consultation. 

DISCLAIMER: The Doar, Drill, and Skow blog is intended for general information purposes only and is not intended as legal or medical advice. References to laws are based on general legal practices and vary by location. Information reported may come from secondary news sources. We do handle these types of cases, but whether or not the individuals and/or loved ones involved in these types of situations choose to be represented by a law firm is a personal choice we respect. Should you find any of the information incorrect, we welcome you to contact us with corrections.

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