September 19, 2023
Each year millions of medical insurance claims are denied, leaving consumers disappointed and facing severe health and financial consequences. What many believe should be a simple process, resulting in their being reimbursed according to their health care plan guidelines, is often frustrating and incredibly challenging. They have learned that sometimes, even when they do everything correctly, they end up disappointed with the outcome. When health care insurance claims are at the heart of the matter, this seems to be true more often than not.
You see, health insurance companies are well-known for denying claims.
Many consumers mistakenly believe that their health insurance carriers have their policyholders’ best interests at heart.
Unfortunately, they don’t. Their loyalties do not lie with their policyholders, but instead with their shareholders: their ultimate goal is profitability.
It is important to understand that the health insurance premiums you pay are recognized as revenue; they positively impact the financial well-being of the company. However, every claim they pay is categorized as an expense, a transaction which negatively affects bottom line profits. Because of this, it is in the companies’ best interests to minimize the number and amount of paid claims. Thus, each year millions of individuals are notified that their claims are denied.
Across the country, including in Oklahoma, many individuals believe that insurance decisions are final and that they have no recourse. This, however, is untrue. There are steps you can take to have your case reviewed and affect these decisions. A seasoned denied health care claims attorney can help. Below we have shared what to do if your health insurance claim is denied.
Why Are Health Insurance Claims Denied?
Knowing the Reason Can Guide Your Actions
Has your health insurance claim been denied? If so, take some time to identify why. There are a number of explanations why insurance companies refuse to pay claims. Knowing the reason why yours was not approved can help you determine the best steps to take.
The five most common reasons why claims are denied are:
- Procedures Not Covered: Unfortunately, not every health insurance plan provides coverage for every test, pharmaceutical product, or procedure, even when they are deemed necessary. When this happens, your claim may be denied, and you, as the patient, would need to pay for the treatment yourself.
- Incomplete or Erroneous Claims: In most cases, your physician’s office is responsible for submitting your claim for payment/reimbursement; but sometimes patients submit on their own behalf. In either case, if there is missing information or if there are errors, or if the claim was not filed within the appropriate time frame, it may be denied. Mistakes are common in claims submitted by both patients and professionals. As an individual, you may not have completed the form in full, and missing information can invalidate your claim. In most cases, your physician’s office is responsible for submitting paperwork to the insurance company. Part of the information they provide includes CPT (Current Procedural Terminology) Codes that correspond to the services you received. With thousands of codes in use, it is not surprising that errors are made.
- Out of Network Providers: Health insurance plans have a list of providers (including physicians, hospitals, surgical centers, pharmacies, physical therapy centers, treatment centers, etc.) that are part of their network. If you are treated by a physician or in a facility that is not part of that network, your claim may be denied or paid at a significantly lower rate. Be advised that sometimes your doctor may be in network, but the surgical center or hospital in which they operate is not. This would result in an issue with payment.
- Not Medically Necessary: Sometimes insurance companies and physicians will disagree on the necessity of the treatment provided. If your insurance company does not believe you needed the treatment you received, they can deny your claim.
- Coverage Maxed Out: Health insurance plans have limits on the amount of money they will reimburse. In cases of serious illness or injury, treatment can be complex and costly. Those suffering often reach the maximum payment prior to recovery. When this happens, claim amounts above the max pay can be denied.
Once you understand why your claim was denied, you can determine how best to proceed. We know that understanding your options can be challenging. A health insurance claims attorney can explain your options to you.
Understanding Your Insurance Company’s Response
Rejected or denied? While the terms seem similar, they do, in fact, have different meanings with regard to health insurance claims.
How Do I Dispute a Rejected Claim?
Most claim rejections occur because of errors in the submission process. In many cases, a formal dispute is unnecessary. You or your physician can simply resubmit the paperwork with the correct information.
First, contact your insurance company to understand the exact reason for the rejection and confirm exactly how to resubmit your claim. Make sure you get the names of the individuals with whom you speak and keep copies of everything you submit (along with notes documenting the timeline of the process).
Some cases involving errors with medical billing are more complicated, and the assistance of a denied health care claims attorney could prove invaluable.
How do I Respond to a Denied Health Insurance Claim?
If your health insurance company states that they will not pay for a submitted claim, then it has been denied. Take a deep breath and understand that you do have recourse. Engaging the services of an experienced denied insurance claims attorney should be your first course of action.
Managing an insurance appeal is both complicated and time consuming. A seasoned professional will manage the entire process on your behalf. Because they understand both Oklahoma and federal health insurance laws. Oklahoma City health insurance claim lawyers can help determine the reimbursement and compensation you are entitled to receive.
Additionally, insurance companies take cases handled by lawyers seriously.
They know they are dealing with professionals, ones who understand the laws and processes regarding insurance claims, as opposed to a consumer who is frustrated by their claim denial. In cases like this, as in most of life, knowledge is power.
Your health care insurance attorney will investigate your claim to determine exactly why it was denied. Most health insurance companies tend to make coverage decisions based on general information. The volume of cases they see is extreme.
Unfortunately, medical care is rarely simple, and what may not be necessary (or may be deemed excessive) for one person may be critical for the health and well-being of another. Your attorney will take the time to carefully review your specific situation and show why the performed service was necessary.
Additionally, they will communicate with the insurance company and your physicians, ensuring complete and accurate information is provided and a complete review is performed.
What if My Insurance Company Acted in Bad Faith?
In some instances, denials by insurance companies are simply the result of not fully understanding the scope of the situation. In cases like this, your denied health care insurance attorney can gather all relevant information and communicate exactly why the claim should be paid.
On the other hand, not every denial occurs because of an innocent error or misunderstanding. In fact, many are the result of insurance company bad faith. As a customer of an insurance company, you are entitled to have your claim reviewed by qualified, unbiased professionals (trained doctors or nurses). Additionally, your claim should be reviewed in a timely fashion.
If the individuals who denied your claim were unqualified, or if they “slow-rolled” the process, you may have been a victim of bad faith. In situations like this, you may be entitled to damages beyond reimbursement for medical costs, including attorneys fees, court costs, and interest.
Doug Terry Law Can Help You
Contact Us Today to Schedule a Free Consultation
If your health insurance claim has been denied, you are likely under considerable stress. Recovering from illness or injury is difficult. Medical care, even with insurance, can be costly. Denied claims put the burden of full payment on the patient, an act which can impact their financial stability, and even their health, forever.
At Doug Terry Law, our health insurance claim denial lawyer is knowledgeable regarding state and federal laws and is experienced in managing cases in Oklahoma. Additionally, he has a proven record of success, helping countless individuals effectively address their denied claims.
We understand the pressure you are experiencing; each day your claim goes unpaid can be excruciating. Thus, we are ready to go to work for you immediately. Reach out to our team today at 405-463-6362 to schedule a free consultation. This meeting provides us the opportunity to learn more about your specific situation and share how we can best help you move forward and resolve your insurance issues.
You deserve to have your claims reviewed in an unbiased, professional, and timely manner. If you are struggling with your health insurance claims, we can help!