How To Dispute Insurance Claim Denial – You’ve probably seen the stories: A patient goes to their doctor or the emergency room for medical care and ends up with a huge bill weeks later that their health insurance provider refuses to pay — even for tests and services the doctor recommended . Debt can be crippling.
Denials of health claims are common. According to the Kaiser Family Foundation and Kaiser Health News, insurers in the Healthcare.gov marketplace rejected nearly one in five claims (19%) submitted for in-network services in 2017. Only a fraction (0.5%) were contested, it showed KFF analysis.
How To Dispute Insurance Claim Denial
“The analysis finds huge variation between insurers, with average refusal rates ranging from 1% to as high as 45%,” KFF reported.
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First, know that denying a claim doesn’t mean your insurance company won’t eventually pay the bill. Here are some 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 have been refused and ask what you can do to overturn the decision. Ask about billing errors or missing information. As frustrating as it may be, be persistent. It may take several calls from you and your healthcare provider’s office to reverse the denial.
Check to ensure that the procedure or service has been coded correctly. Call your doctor’s office and explain that your claim was denied. Mistakes happen and a simple correction of the code assigned to the medical service can solve the problem.
Request your health insurance records. If your insurance company’s response to your questions about a denied claim is unsatisfactory or you feel sympathetic, you have the right to obtain your health insurance records and any speech about coverage restrictions in a timely manner.
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File a complaint/appeal. If you have not been able to change 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 see the Patient Advocate Foundation (PAF) page on how to navigate an appeal. You can also ask the PAF about counseling services available for appealing an appeal.
To keep a record. It may take several calls, emails and conversations to reverse a denial or appeal a denied claim. Keeping a log of all correspondence and conversations with your health insurer – including dates, times and details – will be beneficial if you eventually, as a last ditch effort, decide to seek legal help to fight your denied claim.
Don’t hesitate to fight for a mental health declaration. Mental health coverage is just as important and valid as insurance for any other health need. According to an article in STAT, denial of a health plan should not be accepted as “arbitrary and final.” The writer highlights a 2019 case in which UnitedHealth Group lost a class action brought by 50,000 patients after one of its arms, United Behavioral Health, denied coverage for mental and behavioral health care.
This option may be more suitable for complex cases involving large invoices. You can hire a medical billing 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 attorney through referrals, asking if they have experience with cases similar to yours, and looking for one that offers a free initial consultation. You can also contact the benefits manager at your company to ask if they have resources in this area. If your attorneys discover that the insurance people are misinterpreting the terms of your policy or misrepresenting established facts, they may be charged with bad faith.
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Many West Virginia residents are finding out the hard way that their insurer is not their friend in need and the company has no intention of honoring its obligations when it comes to paying claims. When you buy home insurance, the policy is a legal contract and both parties have rights and obligations. You paid your premiums on time and now you expect them to fulfill their legal obligation and cover the damage to your home. If your valid claim has been denied or if the company has unreasonably delayed investigating your claim, it’s time to seek out the best West Virginia homeowner’s insurance claim denial attorneys and let them recover the money that you are owed.
The wording of the denial letter and the firm voice of your insurance agent delivering the bad news can make you think the decision is final. This is the end of it, go find your money elsewhere! Insurance company representatives use such intimidation techniques to discourage you from pursuing your claim further. Don’t expect them to even mention the possibility of an appeal. However, under West Virginia law, you have the right to file an internal appeal to ask them to reconsider your case. It depends a lot on how you go about it at the moment.
If you beg them to reconsider your case, they won’t be impressed. They know very well that you badly need money to fix your house, but they also need money because insurance companies are used to making huge profits.
What you need right now is a lawyer in Charleston who can formulate a compelling and very to the point appeal. An experienced lawyer will present the legal arguments that justify your claim and raise their reasons for rejecting your claim for money.
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The insurance company is obliged to send you a motivation letter explaining why your claim was rejected, for what reasons. You should get a qualified insurance claims attorney to help you understand why your claim was denied, as it will certainly not be written in plain English, but in legal language. Your attorney will then review your insurance policy, including the fine print and exclusion clauses, to see if their denial is warranted or not.
If your attorneys discover that the insurance people are misinterpreting the terms of your policy or misrepresenting established facts, they may be charged with bad faith. Your attorney will state this in the appeal letter so they know they can’t mess with you.
When you file an internal appeal, the insurer is required to review your case. If your lawyer thinks it’s necessary, you can submit new documents to prove the validity of your claim.
At this point, the insurance company may reconsider their original decision and award you the damages you requested. If they don’t, your lawyer will prepare a lawsuit. If the case goes to trial and the insurer is found guilty, the judge can order the company to pay punitive damages in addition to the money owed to you for your losses. First, obviously. It is a psychological term often used to describe a natural defense mechanism where we ignore the unpleasant feeling.
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Second, it is a term that is best described as one of a medical organization’s worst nightmares. You see, the second meaning for denial in healthcare happens when an insurance organization does not accept the services provided by a doctor.
Sure, you could say I’m being a little melodramatic. After all, experienced medical billing professionals will be the first to tell you that certain denials are less something you can avoid and more of an inevitability. They have a point.
There are thousands of different reasons for denials and just as many, if not more, techniques to implement within your organization to prevent them. However, this piece is slipping outside the scope of this blog post.
Since many professionals consider them an inevitable part of the medical billing landscape, what can you do when your office receives one?
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After all, if you provided services to a patient…your organization deserves to be paid. However, the medical claims denial landscape is bleak for modern medical facilities. A recent study found that bounce cancellations average 53%.
Such a high rate is not something many organizations can afford, leaving smaller practices with a difficult decision to make.
Not only are you already at a statistical disadvantage when it comes to denying medical claims, you are also at a temporal disadvantage.
You see, most doctors already say they need at least 50% more time with patients. No wonder burnout is destroying the health landscape.
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In other words, that statistic proves that facilities don’t have time. And if these organizations had more time, they would spend it on their customers. I don’t blame them…that’s why these places exist.
Anyway, the point I’m trying to make with all of this is that while paying for a claim by an insurance provider helps keep the lights on, it doesn’t take precedence over the customer’s time.
All this mess brings us to the statistic earlier that highlighted the average cancellation rate of application rejections.
So if time is the main factor in why your organization does not send appeal letters for your medical claim denials, what