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My Insurance Denied Medical Claim – NOTICE: The Office of Healthcare Advocate is currently closed to visitors to the public as a protective measure for the safety of clients and staff. We will continue to provide services via email and phone. You can contact the Office of the Healthcare Advocate by using our online services on our website, by calling our main number at 1-866-466-4446, or by emailing healthcare.advocate@ct.gov
You have been denied, what now? If you have been denied coverage for a service, treatment, medication, etc. from your insurance company, it can be a confusing and daunting process. Don’t worry, you may have options. An important step in understanding what these options are is to understand what was actually rejected and why. If your insurer has decided that it cannot approve coverage for a service or treatment, there are many possible reasons why the request was denied. You should get a document from your insurer called an Explanation of Benefits. This is a document that insurers are required by law to give you that explains how each claim or request for service was assessed. A sample is shown below:
My Insurance Denied Medical Claim
As you will see in the highlighted text, the insurer specifies the reason why the claim or service was denied. There can be many reasons for this, including but not limited to: – Insufficient information about the service you requested – The requested service is not a covered benefit under your plan – While the requested service is covered by your plan, you do not meet the insurer’s requirements “Medical necessity” standard (this is common and can come from many causes). While the insurer in the example above denied the claim, it did so because it received insufficient clinical information about the requested service to decide whether the service met the clinical criteria to be medically necessary. For such a denial, the first step is simple – make sure your provider sent the medical records about the service to the insurance company. While a letter from your provider is helpful, the insurer will usually need to see your medical records, including any relevant labs, x-rays and doctor’s notes, in order to approve coverage. If the provider is in network and did not, the claim for payment may ultimately be denied. If so, the insurer pays nothing for the service, but it is important to understand that you may not be responsible to pay the provider for the service. As an in-network provider, these providers have agreed to do certain things, such as submitting a claim for payment to the insurance company on time, in the proper form, and with the necessary documentation. If the provider does not, they may not be in compliance with this agreement and the insurance company does not have to pay the claim. These agreements usually have a provision that states that a provider cannot hold you responsible for failing to follow the protocol. Out-of-network providers are not subject to these same requirements and have no obligation to send anything to the insurer to help pay your claim unless they have provided you with information stating that they would. As you can see from this simple example, it can be very difficult to know what your rights and obligations are when your insurance has denied a claim. In the next section, we’ll look at some of the more common reasons for claim denials and provide some suggestions on how to understand what needs to be done and what your obligations may be. My Story of Fighting an Out of Network Provider Insurance Denial Jan 18, 202228 min to read
Hidden Charges, Denied Claims: Medical Bills Leave Patients Confused, Frustrated, Helpless
Not only can a health insurance denial claim be stressful because of the financial strain it creates, but also because navigating the denial and appeal process is instantly overwhelming and drains your time and energy. This was the case of Z, a young woman whose true story is shared here.
In 2020, I received a medical denial from my health insurance because I had seen an out-of-network provider. The bill totaled over $2000, an amount for me at that point!
I have cystic fibrosis, or CF, a genetic disorder that leads to severe and often fatal breathing problems. A few months before I received this medical claim denial, I had moved to a rural area in a new state and purchased an Anthem Blue Cross Blue Shield insurance plan from the Affordable Care Act marketplace.
In my new area, this was the only provider available to me at the time. I chose the highest tier Anthem plan available, confident that it would cover my necessary cystic fibrosis treatments and care. In my state, however, there was only one specialized CF center – a 7 hour drive from my home.
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In the summer of 2020, I decided it was time to see a cystic fibrosis specialist in my new condition, so I made an appointment. Before calling the CF center, I checked my insurance’s list of in-network providers. Although I didn’t see the CF doctor’s name listed, I assumed that was because the provider was away. The rest of the providers on the list were all local. I called and checked that the CF center accepted Anthem and thought I was all set, especially since this specialist was the only one in the state qualified to treat my complex disease!
So I visited the CF specialist for a regular checkup, had breathing tests, blood work and various other tests as I have done all my life. Cystic fibrosis care often involves seeing a bunch of different doctors, as the disease affects not only my lungs, but also my gastrointestinal tract, sinuses, pancreas, and more.
A month after that appointment, I opened the letter that started my worst nightmare. It was a medical claim denial from Anthem. I wondered why my insurance denied my claim and saw that their explanation was that the CF doctor was out of my network and therefore the visit was not covered. At first, I thought this would be an easy issue to clear up, so I called my security.
I should have taken that first phone call as a sign that my insurance provider wasn’t going to give in easily. That morning I spent over an hour on the phone with Anthem as customer service agents tried to figure out my problem and transferred me from one representative to another. Finally, I was able to speak to someone who offered to help me file an appeal.
Leveraging Artificial Intelligence For Claims Management
The first appeal was simple, requiring only a formal request by telephone. A month later, however, I received a second denial letter, saying that Anthem had reached the same conclusion about the denied health insurance claim as the first time. Looking at the amount I owed the doctor, I’m pretty sure my heart skipped a beat or two. So I called my insurance provider again and was put on hold and transferred until I could speak with a denied claims representative who escalated the matter for a second appeal. This time, the agent told me that Anthem would require a letter from my doctor to have any chance of a successful appeal.
Somehow I found time in the middle of my busy work schedule to traverse the phone tree at my office to request a letter explaining why it was absolutely important for me to see a CF specialist and not just a pulmonologist (lung doctor). Having been seen in CF clinics for as long as I could remember, I knew that my disease required a provider trained to treat CF specifically, as the disease and its treatments are beyond the scope of routine pulmonologist care.
Facing a wrongfully denied out-of-network medical claim? Get in touch today to find out how aJust can help!
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After gathering all the paperwork and filing a second appeal, it was several weeks before I received a second health insurance claim denial. This time, the letter came with a list of in-network pulmonologists that Anthem told me to see instead of a CF doctor. Now I was very stressed. Not only did I realize that I couldn’t stop fighting there because of my financial situation, but I also knew that not being able to see a CF doctor would take a toll on my health.
I was on a special medication that the local pulmonologist knew nothing about and had a sinus infection that required surgery and antibiotic intervention before it spread to my lungs. If there was ever a time I needed to feel secure in my ability to see the right doctor, it was then.
For the next month, I spent most of my mornings before work researching how to best fight this health insurance denial. I contacted attorneys in my area but just found out that the hourly fees and consultation rates would already be way off
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