Pre-Authorization Blues: What to Do If Your Insurance Denies Coverage For a Planned Treatment

July 28, 2024

For reasons many find hard to comprehend, insurance companies in Oklahoma and across the country deny coverage for necessary medical treatments every day. Because insurance companies are businesses with goals of profitability, actions like this that minimize expenses and benefit their shareholders makes sense.

Unfortunately, denying pre-authorization requests for necessary medical treatment puts their policyholders in precarious positions; they are unable to receive the medical treatment they need.

Sometimes, even when you, as a medical insurance policyholder, do everything right, including requesting the necessary pre-authorization, you still don’t get the answer you need. The good news is that you do not have to accept the insurance company’s first response as final.

Consulting with a seasoned health care insurance denial attorney in Oklahoma may be in your best interests. The insurance process is complicated; frankly, the odds are stacked against you. The advice and counsel this professional can provide can help you understand the situation and respond appropriately.

What’s the Purpose of Insurance Pre-Authorization?

Pre-authorization is an operating procedure used by insurance companies to ensure that the treatments prescribed for their policyholders are, in fact, medically necessary, safe, cost effective, and appropriate.

If your physician orders any type of treatment or test that requires pre-authorization, they would communicate directly with your insurance company, providing them details about your diagnosis, the requested testing, medication or procedure, and the provider’s location. Your insurance company will then review that information, request additional details if necessary, and issue either an approval or denial statement. The response time for pre-authorization can vary depending upon your diagnosis and the doctor’s request, but it is possible to fast-track the process in certain situations.

Why Pre-Authorization Denials Happen

Denials in response to pre-authorization requests are not uncommon. In fact, they are a regular occurrence.  Some of the most common reasons insurance companies issue these denials include, but are not limited to:

• Administrative Mistakes: Frequently seen administrative mistakes that result in pre-authorization denials include the misspelling of the patient’s name, wrong birthdate, and incorrect insurance billing codes. Simple typographical errors can make a significant difference.  Additionally, if required information, like a diagnosis, is missing, a denial of a pre-authorization request can occur.
• Disregard for Procedure: Pre-authorization means that the insurance company must okay your treatment prior to its being performed. If treatment is provided before the okay is received, your insurance company can refuse coverage. The requirements regarding pre-authorization must be observed.
• Medical Necessity: In general, procedures that require pre-authorization tend to be costly to perform. In order to okay expenses like this, insurance companies carefully review medical history to determine if the exact process requested is necessary. In order to be approved, the treatment must meet certain standards common for the diagnosis. If it does not, a denial will be issued.
• Cost: Insurance companies may also require individuals to exhaust any over-the-counter or less expensive treatments prior to approving one that is more costly.  Insurance companies will review requested procedures and medications to determine if a less expensive option is available. If so, they will deny the initial request in favor of something that is an option. For example, generic medication may be a more economical choice than a branded one.
• Lack of Coverage: Not all insurance policies cover all procedures. If your coverage excludes the procedure prescribed by your physician, your pre-authorization request will be denied. This happens often with cosmetic procedures or other treatments, like some for cancer, that may be declared experimental.

Clearly, the reasons behind pre-authorization denials are broad-based and vary from situation to situation. Addressing the basis behind the denial is the first step toward receiving the treatment you need.

Your Path to Overcoming a Denial

The road to overcoming a denial is rarely straight, but with the correct guidance it can lead to positive results. Navigating this trip can be overwhelming; the process is complicated. Engaging an experienced denied healthcare insurance attorney to represent you can be incredibly valuable. This professional  can help compose a request for an appeal letter to be sent to your insurance company.

The steps to appealing a denied pre-authorization request include recognizing the reason for denial. You cannot effectively appeal to what you do not understand. Carefully review the denial letter from your insurance company to comprehend exactly why the pre-authorization request was turned down.

Next, you will need to collect relevant documents. Make sure you have a copy of your insurance policy, the denial letter, your initial submissions, the request from your doctor and all medical records.

You will need to ensure the pre-authorization request was submitted without errors and included all necessary information. If the issue at hand was administrative in nature, you can work with your physician to resubmit it correctly.  However, if the denial was based on another reason, drafting and submitting an appeal letter may be in your best interests. You should work with your attorney to ensure the letter includes all necessary  information and is submitted in accordance with the requirements of your insurance company.

Health insurance companies tend to respond more quickly and more positively when policyholders have secured legal assistance. They recognize that they are not always operating from a position of power and may be more likely to provide an independent and honest review of your case, approving your pre-authorization request if it was initially declined inappropriately.

Don’t Give Up!  Additional Resources

Dealing with a pre-authorization denial is frustrating — you are being made to wait and restate your case in order for the insurance company to okay medical treatment that your physician has deemed necessary for your health. It is important to know that you do have the option to appeal their decision and that engaging professional representation can alleviate the uncertainty associated with the steps and increase your chances for success.

The bottom line is that insurance companies often inappropriately deny pre-authorization requests because they know that many policyholders will simply accept their word as final and assume the costs of necessary treatment themselves or not pursue the medical assistance they need.  In both cases, insurance companies recognize significant monetary savings and don’t need to invest in costly procedures or treatment.

Contact Doug Terry Law Today

Identifying the right professional to help you with your denied pre-authorization claim is an important first step in the appeals process. For decades, Attorney Doug Terry  and his team have worked with individuals in Oklahoma addressing their pre-authorization denials. Their knowledge of the law is significant, and they are well-versed in the tactics insurance companies take to deny appropriate requests.

Mr. Terry’s reputation for providing compassionate and successful service is outstanding.

He understands the stress facing his clients as they fight to get the treatment they need. As your attorney, he will adopt your goals as his own and leverage his knowledge and experience to impact a positive outcome. Your well-being is his ultimate concern.

Contact Doug Terry Law today at 405-463-6362 to schedule a free consultation regarding the denial of your pre-authorization.  See firsthand how he communicates and learn what he can do to help you.