Given the high cost of medical insurance, it can be very frustrating to have to battle your health insurer to have them pay for medical testing, procedures, or medication. If you have an insurance claim because you were sick, needed a medical procedure, or experienced some type of accident or trauma, it can be overwhelming to battle your insurance company, in addition to coping with your own injury or illness.

You do have options if your insurance company refuses to pay a claim or does not pay their full portion of it. Staying patient and keeping proper records will help you and ultimately increase the chances of getting the claim paid.

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. 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

Review your health insurance policy to find out what it does and does not cover. Know in advance if you’re required to go to a specific hospital for referrals and what tests or procedures need a pre-authorization. You should also know 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 care. If your insurance favors one hospital system, for example, you 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, insurers are required to provide you with an explanation of benefits (EOB) detailing the claim they received and the amount they intend to pay. The EOB contains further important information such as details about the service provided, how much the bill was, and 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 and have them explain why they are 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 their decision about a claim, you are entitled to file an appeal.

Filing 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. Some insurance companies are aggressive about denying claims, assuming 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. Appeals are time-sensitive, so make sure you know how long you have to file. The initial step in filing an appeal is usually not complicated, so make sure you file it on time.

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 stating why they 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.

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 treatment or test was covered under the policy.

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 get paid, so it is in their interest to assist you in obtaining coverage for the claim. If necessary, seek legal counsel. Most importantly, do not give up. It may take several rounds of appeals before a favorable coverage decision is made.  

Since 1883, the attorneys at Doar, Drill & Skow have represented families, individuals and businesses across Wisconsin and Minnesota in areas of personal injury, criminal defense, family law and divorce, civil litigation, estate planning and trusts, workers compensation, and more. We are recognized as one of western Wisconsin’s most skilled and successful personal injury law firms and have built our reputation on what we achieve for our clients. We are committed to being your advocate, regardless of your circumstances. Located in New Richmond, we serve clients throughout western Wisconsin and Minnesota.

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.