How to Fight a Healthcare Insurance Denial?


  • Author Isabella Bautista
  • Published June 1, 2022
  • Word count 693

Many Americans increasingly find themselves dealing with huge medical bills after medical procedures their healthcare insurers should have covered. All too often, the insurance company says "it's not our problem, talk to the hospital;" the hospital says "it's not our problem, talk to your insurer;" and the insured is left holding the bag, often at a time they're already dealing with the stress of major surgery or illness.

The good news is the US govt has specific laws enforced to hold their healthcare insurer accountable. Insurers must follow the specific terms of the policy contract and cannot deny coverage for medical bills without a valid reason. If insurers fail to live up to their obligations, the insurer has legal rights under Washington's Consumer Protection Act and Insurance Fair Conduct Act, or the federal Employee Retirement Income Security Act, to seek a court order requiring coverage and requiring the insurer to pay the insured's attorney's fees as well.

Unfortunately, fighting a healthcare insurance denial takes significant time and effort, which can be hard when you're already recovering from surgery or illness. This is why many healthcare carriers have been criticized for making the process difficult and confusing in the hope that patients will simply give up without fighting the denial.

There are three common reasons why healthcare insurance claims are denied:

The insurer determines the procedure, treatment or medicine was not "medically necessary." The definition of "medically necessary" depends on the specific policy, but, generally, when the insurer says the procedure wasn't medically necessary they basically mean "we don't believe you really needed it." Sometimes the insurer uses the same rationale to deny coverage on the basis the treatment is supposedly "experimental."

The hospital or doctor who provided the treatment was out-of-network, meaning the provider didn't have a contract with the insurance company. Most healthcare insurance severely limits or eliminates coverage for out-of-network providers.

The doctor or hospital who provided the care used improper billing and coding, causing the insurer to reject coverage because the hospital didn't properly document what care was performed.

The good news is many people successfully fight their healthcare insurer's denial of coverage. Each of the three common reasons healthcare claims are denied can be subject to attack:

Denials on the basis that treatment was not medically necessary can often be fought with the support of the doctors who prescribed the treatment or care at issue. Too often, healthcare insurers misread, gloss over, or outright ignore a physician's rationale for prescribing treatment. Especially where treatment is expensive or time consuming, insurers have a powerful temptation to "skip" the medical records demonstrating the patient needs the treatment in order to justify denying coverage for treatments that will cost the insurer a lot of money.

Denials for out-of-network treatment can be fought by insisting the insurer follow the policy contract and the federal Affordable Care Act (a/k/a Obamacare). Often, the policy contract requires the insurer to provide at least some degree of coverage even where the treatment is out-of-network. Furthermore, if the patient is treated by an out-of-network provider for emergency care, the Affordable Care Act requires the insurer to treat the care as though it was provided in-network.

Improper billing and coding by the hospital can often be challenged by a thorough review of the medical records, procedure codes and billing codes.

Importantly, your insurer cannot deny healthcare care coverage without a reasonable explanation. This means you have the right to know specifically why coverage was denied and to get the information you need in order to fight the denial. Most healthcare insurers are required to allow you to "appeal" the denial before going to state review by an independent third party.

Lastly, in fighting a healthcare insurance denial, be mindful of the applicable deadlines. All healthcare insurance disputes are subject to deadlines that will cause the patient to lose their right to challenge the healthcare coverage denial if the patient fails to act within a certain time period. The specific deadline varies, so it is critical to be diligent and stay aware of any applicable deadlines when fighting a healthcare coverage denial.

Read More:

Isabella Bautista is a dedicated healthcare professional. Ms. Isabella Bautista' command over various medical topics gives her an edge as a content writer and sets her apart from the rest.

Article source:
This article has been viewed 647 times.

Rate article

Article comments

There are no posted comments.