Medical debt is a huge problem in the United States. It is the leading cause of bankruptcy, and the burden of medical debt prompted the creation of laws that help make health insurance more available to all. So, what happens when you get health insurance and the insurance company still refuses to pay?
The good news is that you may not be completely out of luck. There are many reasons insurance companies deny coverage. Not all of these reasons are legitimate, and there are ways you can push back when insurance companies don’t live up to their responsibilities.
Why do insurance companies deny claims?
Insurance denials can start with anything ranging from simple typos to decisions made by doctors working for the insurance companies. You likely know to make sure you work with in-network providers, but many of these problems are completely out of your control. Common problems include:
- Out-of-network providers
- Incorrect or incomplete paperwork
- Billing code errors
- Failure to request pre-approval
- Disputes over treatment costs
- Questions about medical necessity
Some of these problems, such as disputes over cost, may lead to partial payments, rather than complete denials. Still, few people can afford to cover the gaps the insurance companies decide to create. Instead, when you find yourself facing a surprise bill, you want to know your options.
Getting the coverage you deserve
Naturally, your path forward will depend on your specific problem. That said, the first step is usually to make sure you have all the right information. This means contacting your hospital or provider for a detailed bill and asking the insurance company to explain why it denied your claim. Sometimes, this will lead to an simple resolution, such as if the hospital realizes it entered the wrong billing code.
In other cases, you may need to appeal. This is often the case in two common situations:
- The insurance company says your treatment was not medically necessary. Insurance companies often have doctors on their payrolls review claims. These doctors will review your medical records and the treatment, and they will make decisions about your treatment without ever meeting you. The doctor you worked with personally should have a better understanding of your needs.
- The insurance company refuses to pay what your hospital billed, claiming the cost was more than the “usual and customary” charges for treatment. You will likely have no idea what the “usual and customary” cost should be, but this is essentially the insurance company’s way of saying it should not have to pay the full cost. Somewhere else, someone else is billing less for a similar procedure, and the insurance company wants your provider, wherever you are, to pay less, too. If this is the problem you face, you are likely not alone.
Insurance companies aren’t exactly known for being easy to work with. When you have a problem like either of these, it can feel impossible. Even hospitals and doctors struggle with insurance companies and insurance denials. However, you don’t have to stand alone against your insurance company. Your insurance company has a legal responsibility to fulfill its duties, and you can work with an attorney to hold the insurance accountable.
Do you need help with an insurance denial?
Doctors, hospitals and insurance companies are supposed to work together. They are supposed to help you get the treatment you need and to avoid burdening you with staggering debts. That is, after all, why you pay for health insurance in the first place.
It may be hard to understand why your insurance company denied your claim, but the first step is to get more information. After you get the information you need from your healthcare provider and insurance company, you can meet with an attorney. An attorney who works with insurance denials can help you understand your denial and your options.