Reasons for Health Insurance Claim Denials
Dealing with health problems is challenging enough, but when your insurance provider refuses to pay or underpays you after you make a claim for medical care, you can be left with large bills you can’t afford. Your provider may refuse to pay for a treatment, procedure, or test after you’ve had it done. They may do this during a pre-authorization, before the service is even scheduled or performed. Along with added stress, this denial may create other issues you may not want to deal with.
Top Possible Reasons for a Denial
There are numerous reasons why a health insurance provider may decline to pay for the healthcare service you need. Some denials are simple and easy to address, while other are challenging at best:
- Paperwork mix-ups and errors are common. They can range from a misspelling of your name or a wrong address listed on your claim form.
- The medical necessity of the service is questioned. Your insurer feel you don’t need the treatment, or that you do need it, but they need more proof. For the latter, the insurer may ask for more information from you and your doctor about why you need the service.
- They want to control the cost. Your provider may want you to use a less expensive option.
- The service you need isn’t included in your plan. Even though you may think you have great insurance, the service you may not be a listed benefit.
- In- and out-of-network issues. Some services are only covered if they are within your insurance providers’ network of coverage. Many facilities and specialists may not be included in the insurer’s network.
- Missing or incomplete information. You may not have provided enough information for the pre-authorization or the final claim.
- Each health plan has its own rules. You may need pre-authorization for a medical service. If you receive a service before that, your claim may be denied.
How to Deal with a Denial
It doesn’t matter whether your claim for a service you’ve already received was pre-authorized or not. A denial is always frustrating and stressful. If you are denied, you can appeal the decision. Every health care plan has an appeal process. Be sure to record every step you take to resolve your denial. Write down the name of every person you speak to, especially if this is done on the phone.
You may not be able to resolve the situation directly with your health plan provider. If this happens, you can request a neutral third party to review your denied claim. The process can be exhausting, but a dedicated and experienced attorney can help you with your appeal. They will look over your policy, review the steps you’ve taken, and act on your behalf to get you the settlement you need. If your health insurance claim was denied or underpaid, contact Louis Law Group at (954) 676-4179 for a free no-obligation consultation or case evaluation. Your health is vital to you and your family – and to us!