What should we do if our health insurance claim for benefits is denied?

Answer:  It’s safe to say that most insureds have dealt with some type of insurance obstacle, whether it was a billing error that seemed nearly impossible to correct, a medication/procedure/treatment that was unfairly denied, or an outright health insurance denial of benefits. While insurance complications like these can be incredibly frustrating, overwhelming, and financially draining, there is another denial tactic used by insurance companies that is absolutely appalling: the insurance denial AFTER an authorization has been granted, and AFTER the procedure is already completed.

How can this be? How is it possible for an insurance company to deny a procedure, after it has already been approved? There are several reasons for this type of insurance denial, and understanding these reasons can help you to (1) prevent denials, and (2) advocate for your benefits even after the denial.

First, you should understand that procedures (for example, a back surgery for a herniated disc) must be considered “medically necessary” to be covered by your insurance company. The law is clear that medically necessary care must be provided, however, there’s a catch: your insurance company can review your case for medical necessity both before and after a procedure. Thus, it is possible for them to come to a different conclusion after your procedure has been completed, which could mean an insurance denial…and a massive and unexpected bill.

So, what can you do to protect yourself against this type of insurance denial?

1. Get it in writing! Be sure to request a copy of your authorization letter from your insurance company, as well as a confirmation letter from your physician stating that he/she plans to perform the same procedure that has been authorized.

2. Know the Code: It is critical that the procedure code listed on your authorization letter is the same code that is billed by your healthcare provider. If your healthcare provider submits a code that is different from your authorization letter, your claim will probably be denied. Watch out for simple coding errors!

3. Appeal the decision: An insurance denial, whether it is before your procedure or after your procedure, is NOT the final word. The appeal process is complicated, but it is often worth the effort! Pay attention to time limits and deadlines, and if you do not feel well enough to file an appeal, you may want to reach out to an experienced attorney for help.

Glenn Kantor, Esq.
Kantor & Kantor, LLP
Northridge, California

How to Deal With Surprising Health Insurance Denials was last modified: June 28th, 2018 by Phil Sanders