Getting a health insurance claim denied is more than just an inconvenience—for some it can be make-or-break financially, or affect ongoing healthcare. Read on to find out how to prevent your medical claims from being denied and what to do if they are.
What Does a Health Insurance Claim Denial Mean?
When health insurance companies deny medical claims, they refuse to pay for a service that you received from a medical facility and then submitted to your insurance for coverage. When this happens, you may suddenly find yourself facing an unexpected bill.
Since health insurance companies in the US are looking out for their best interests, they may deny medical claims even if they were essential to your ongoing healthcare. Here are some of the reasons they will give for their decision:
1. Claim Errors
One of the most common reasons for a health insurance company to deny medical claims is an error on the claim form. This can be as simple as a misspelled name or missing piece of paperwork. Sometimes claims are also mistakenly sent to an outdated insurance company, or sent so late after the date of service that they miss important deadlines.
Another potential claim error that can result in denial is not seeking out prior authorization for a service. For example, you may be instructed by your doctor to get a CAT scan for a broken bone without realizing that this test needs to be approved by your insurance first. While this type of denial may seem simple to solve, it still can be quite a pain to figure out.
2. Not Medically Necessary
Sometimes health insurance companies will deny medical claims that they see as “not medically necessary.” This typically means that there is an alternative treatment that costs less, or that the claim represents a medication or procedure that is wanted, not needed.
Imagine getting prescribed Botox injections for migraines, then finding out that your health insurance denied the prescription claim because Botox is often used for beauty purposes. If you have been recommended a treatment by your doctor that your insurance company then decides is not medically necessary, it can be extremely frustrating.
The good news is, you don’t have to fight a medical claim denial on your own. Call now to speak to an expert today!
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3. Out-of-Network Provider
This reason for a medical claim denial is probably the easiest to avoid. Most health insurances offer a list of their in-network providers, or the doctors that are contracted with their company. Health insurance companies often deny medical claims for appointments with doctors who are not in your insurance network.
Sometimes, you may not be able to find an in-network specialist to treat your specific medical condition. If you choose to visit one anyway, you may have to fight for a health insurance appeal to get your claim covered.
4. Service Not Covered
There are some services, such as fertility treatments or vision care, that may simply not be included in your health insurance plan. Denied dental claims are also common with many health insurance companies in the US. Even if a service is necessary to maintain your health, you may receive a denial after submitting a claim for a service that is not covered. This is why it is important to read that fine print on your insurance plan!
5. Experimental Procedure
In order for a healthcare treatment to be covered by insurance, it needs to have tested and given the FDA’s stamp of approval. This means that, if a doctor offers you a new, experimental procedure to help treat your condition, chances are it won’t be covered by your insurance. Unfortunately, your health insurance company may also deny medical claims under this reason even if the procedure has approval, is accepted by the medical community, and has been common practice for years. That’s when it gets tricky to fight.
What to Do About a Claim Denial
So what do you do when facing an unexpected bill thanks to a health insurance denial? The first step is to give your insurance company a call and find out the reason for the claim denial.
The next step is to get a medical appeal form to challenge the company’s decision. The issue is, there are so many factors that go into whether or not a claim gets denied, that you need to gear yourself up for quite the fight. This can mean dozens of phone calls, additional paperwork, and the patience and willpower to keep pushing until your claim is resolved.
That’s where aJust Solutions comes in
With our expertise in all the complex laws that govern health insurance companies, and our experience getting people covered for the medical services they need, you can trust us to give your claim the best chance possible at approval. Because overturning a denied claim is all about in-depth knowledge and time consuming perseverance.