Common reasons why health insurance claims are denied

Common reasons why health insurance claims are deniedNavigating a serious medical condition can be a stressful experience, but for many, the worst part of the process doesn’t play out in a hospital or medical office, but in the billing and paperwork that follows. If your health insurance claim is denied, overwhelming stress can be the immediate response. Many people are driven into bankruptcy by medical debt, and even those with health insurance sometimes find themselves at risk of serious financial turmoil.

Working with a skilled health insurance claim denial lawyer can ensure that you or your loved one gets the full benefits you are entitled to. Attorneys who specialize in this field of practice understand the intricacies of health insurance fine print, and also know how these cases are handled in local courts of law. Don’t let the insurance company deny you the coverage you’ve earned.

Why are some health insurance claims denied?

There are many reasons an insurance company can use to try and deny your claim. Some are more easily disproved than others, but there are often legal remedies that can help. Understanding some of the more common reasons for a denied claim can help you know when to seek legal representation to defend your rights under the law.

Incomplete or inaccurate information

This is one of the most common reasons given for denying a health insurance claim. If there is any significant information that is not included in your health insurance claim, the insurer will often immediately deny the claim without investing any time tracking down the missing information.

Fortunately, this is also one of the easiest reasons for denial to appeal. If your health insurance claim is denied for missing or inaccurate information, your doctor or extended medical team may be able to help. Your attorney will reach out to these professionals and their recordkeeping staff to find the missing or inaccurate information and provide it to the insurer.

Insufficient medical necessity

This basis for rejecting a health insurance claim can be a bit more difficult to overcome. When the insurance company claims that a treatment or procedure was not medically necessary, the burden falls on the patient to prove otherwise.

Here again, a skilled attorney will work with your health care team to fully document the diagnostic criteria used to create your treatment path. This might require collecting lab reports, screening results, digital or film imaging, and other documentation. Once a strong evidence base is established, the information will be shared with the health insurance company along with instructions to process the claim again.

Lack of prior authorization

Somewhere deep within the documents that came with your health insurance policy often lies a clause regarding the need to obtain prior authorization before receiving treatment. There are sometimes steps that must be taken to meet this requirement. You may need to submit paperwork or have your doctor submit on your behalf. Sometimes all that’s required is a phone call before treatment begins.

In many cases, however, the patient’s focus is not on jumping through hoops to meet insurance needs, but on finding relief from pain or other symptoms. If you failed to meet the insurance company’s prior authorization guidelines, an attorney may be able to help by gathering evidence to support your need to act quickly to get the care you needed at the time of the illness or injury.

Claim exceeds coverage limits

This type of denial occurs when the amount of your health insurance claim exceeds the amount of coverage the policy provides. The first place to begin with this type of denial is to check your billing history to determine if you have in fact exceeded your coverage limits.

Medical billing is an industry notorious for errors and omissions. It’s worth taking a closer look to ensure that both you and your insurance company are working with the same set of numbers. If it turns out that you have exceeded the coverage ceiling, your attorney can work on your behalf to negotiate a settlement agreement with the doctor’s office or hospital. It’s easier for the billing party to accept a lesser amount than to spend time and resources trying to collect a debt that might never be repaid.

How to fight an insurance claim denial

The first step in fighting your insurance claim denial is to collect all documentation you have regarding your medical care, insurance policy, and denial. This includes billing and coverage paperwork, your original policy paperwork, and any logs you may have kept of phone conversations with your insurer or billing agent.

It can also be helpful to create a written overview of the facts in your case. Having a timeline of when events took place can help your attorney determine the best way to proceed.

Reach out to an experienced health insurance claim denial lawyer to discuss the specifics of your case. Be prepared to share information about your denied claim, and take notes so you can easily recall information shared with you about the process and what to expect.

A good attorney will always take the time to answer your questions and address concerns as they arise. You should feel as though your attorney is your partner in the process of navigating a health insurance claim denial. Good communication is essential, and you should never feel rushed or pressured throughout the process.

Is it necessary to work with an attorney when a health insurance claim is denied?

There are certainly cases where simple billing errors or missing information can be cleared up on your own, without the assistance of an attorney. That said, if it appears that the insurer does not plan to reverse the denial, you may want to seek legal assistance.

Keep in mind that many insurance claim denials occur in the pre-authorization part of the process. This can leave you in the position of having to make difficult decisions about whether to seek or delay care. In these cases, an attorney can help clear up the issue of whether your insurance coverage will pay for a treatment or procedure as quickly as possible, moving you one step closer to the care you need to preserve and protect your health and wellness.

For many people, having a trusted legal advisor to turn to can make a world of difference when trying to fight a health insurance claim denial. Some things simply don’t come with a price tag, and peace-of-mind is a great example. If you have questions or concerns about a health insurance denial, reach out to a skilled health insurance claim denial lawyer today to learn more.

Read Related Posts ⁄