What Can I Do If My Insurance Company Denies My Claims?

The Following Are 4 Major Reasons Your Claim Might Be Denied

There can be  a variety of reasons why your health insurance company has not paid certain insurance claims. 

Insurance Company Errors

Possibly your insurance company processed your claim incorrectly, or they may have given you inaccurate information that led to you seeing a doctor or undergoing a treatment that wasn’t covered.

It is also possible that you were incorrectly billed by your healthcare provider. The example of a free, preventive well-woman visit being categorized as a specialist visit is one such example. 

Call your healthcare provider and insurance company first to correct these errors, then if necessary, appeal through your insurance company’s appeals process.

If your insurance carrier requested additional information, your provider might not have provided it or it might have been lost in the processing, leaving your claim pending.

The burden of following up with your insurance company and your healthcare provider is your responsibility, even if it does not seem your fault.

There Is No Network Coverage For This Provider

The fact that a healthcare provider accepts their insurance does not imply that they will be covered. Additionally, you need to verify that this healthcare provider is in the network of your insurance plan to avoid getting an unexpected medical bill. 

If a provider accepts your insurance but is not in-network for your plan, they will bill your insurance company for the service and charge you for the balance. This usually means paying higher, out-of-network costs if you have a PPO plan. 

HMO plans, however, may charge you the entire visit fee. Ensure that your healthcare provider is in-network with your specific health insurance plan, as insurance companies can offer several plans with different provider networks. 

Your insurance company has the final say on what gets covered, so make sure you get confirmation from them directly, not from your healthcare provider.

Bundling Procedures

In the medical billing industry, bundling is another type of misunderstanding between your healthcare provider and your insurance company.

Bundling occurs when secondary procedures are considered part of a primary procedure. Your insurance company may “bundle” the two procedures together if you need an incision before a certain surgery. 

However, your surgeon may only bill you for the surgery claim, leaving you with the incision claim.

You may find that you need help digging through medical billing codes and jargon in these bundling cases.

There Were No Pre Approvals Or Referrals

It’s possible that your insurer will deny your claim if you get medical care without the appropriate referral or preapproval.

You should get a referral soon if this is the case, and you may be able to get reimbursed for past visits now that you have one. The insurance company’s official appeal process may be used if you don’t get a positive response.

If your insurer believes the service wasn’t medically necessary, your claim might be denied.

This can be handled by asking your doctor to submit a “Medical Necessity” form (or any other information required by your insurance company).

The Medical Service You Need Is Not Covered By Your Insurance

Additionally, perhaps your health insurance policy doesn’t cover your medical service.

If you feel that an exception should be made to your claim, speak with a representative of your insurance company to understand why your care wasn’t covered.