You’ve probably seen the stories: A patient goes to their doctor or the emergency room for medical care and winds up with a huge bill weeks later that their health insurance provider refuses to pay — even for tests and services that were doctor recommended. The debt can be crippling.
Health claim denials are common. According to Kaiser Family Foundation and Kaiser Health News, Healthcare.gov marketplace insurers denied nearly one out of every five claims (19%) submitted for in-network services in 2017. Only a fraction (0.5%) were appealed, the KFF analysis showed.
“The analysis finds a huge variation across insurers, with average denial rates as low as 1 percent and as high as 45 percent,” KFF reported.
Health claims can be denied for a variety of reasons, including:
- The service or procedure was coded incorrectly by the doctor’s office
- The service or procedure wasn’t pre-approved by the insurance company
- The service or procedure isn’t covered under your current plan. For example, new technologies may not be accepted by the plan.
- An off-label drug was used to treat a condition that already has an approved medication.
How do you fight a denied health insurance claim?
First, know that a denial of a claim does not mean your insurance company won’t ultimately pay the bill. Here are a few options for challenging a denial:
Make a call (or two or three). The “squeaky wheel” approach can help. Contact your health insurer’s customer service line, explain that you were denied and ask what you can do to reverse the decision. Ask about billing errors or missing information. As frustrating as it might be, be persistent. It may take multiple calls from you and your healthcare provider’s office to reverse the denial.
Check to be sure the procedure or service was coded correctly. Call your doctor’s office and explain that a claim was denied. Mistakes happen and a simple correction of the code assigned to the medical service may solve the problem.
Request your health insurance records. If your insurance company’s response to your questions about a denied claim is unsatisfactory or feels cagey, it’s your right to obtain your health insurance records in a timely manner and any discourse surrounding the coverage restrictions.
File a complaint/appeal. If you haven’t been able to budge your health insurance company’s decision to deny, be aware that state and federal laws protect your rights. Go to MyPatientRights.com and learn how to file a complaint with your health plan and the state agency that oversees health plans. Also check out the Patient Advocate Foundation’s (PAF) page on how to navigate an appeal. You can also ask PAF about counseling services available for fighting an appeal.
Keep records. It may take multiple calls, emails, and conversations to reverse a denial or appeal a denied claim. Keeping a log of all of your correspondence and conversations with the health insurer — including dates, times, and details — will be beneficial if you eventually, as a final effort, decide to pursue legal help to fight the denied claim.
Don’t hesitate to fight for a mental health claim. Mental health coverage is as important and valid as insurance coverage for any other health need. According to an article in STAT, a health plan’s denial should not be accepted as “arbitrary and final.” The writer points to a 2019 case in which UnitedHealth Group lost a class-action suit filed by 50,000 patients after one of its arms, United Behavioral Health, denied coverage for mental and behavioral health care.
Hire a medical bill advocate
This option may be more appropriate for complex cases involving high bills. You can hire a medical bill advocacy firm to help you navigate a denial from the start or you can turn to them after you’ve tried and failed to fight a denied claim on your own. Consumer Reports recommends finding a medical bill advocate via references, to ask if they have experience with cases similar to yours, and to search out one that offers a free initial consultation. You can also reach out to the benefits manager at your company to ask if they have resources this area.
