When Your Medical Claim Is Denied

When Your Medical Claim Is Denied
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By Debra J. Wolf, Supervising Attorney, New York Legal Assistance Group


I work with low-income patients living with cancer, vulnerable people whose life circumstances make it particularly challenging to deal with health insurance issues. The truth is, though, that this complex world is difficult for most of us to navigate -- and never more so than when a medical claim is denied. But before I describe how understanding the system can make all the difference - a little background will help.

Whether you are insured through an employer or union group policy, a privately purchased policy or one of the policies available through the Affordable Care Act, you will have a written plan outlining your benefits, coverage limits and the appeals process - and you need to read it. You must also know whether your policy is an HMO, which allows only in-network doctors, or one that allows for out-of-network doctors which may be at a much reduced reimbursement rate. With an HMO, you generally have a co-payment and sometimes a deductible or coinsurance and that is the extent of your financial responsibility if your doctor is in network; with other policies, your out of network doctor can usually bill you directly for any amount not paid for by your insurance.

Whatever plan you have, all policies can still limit certain coverage. This might include the number of physical therapy visits or home nursing visits allowed per year. If your policy requires pre-authorization, and most do for major medical procedures and radiology such as CT Scans and MRIs, make sure either you or your doctor's office check with your insurance company to confirm that the procedure is approved. If you have an HMO, make sure all your doctors are in network and if you are having surgery, make sure all doctors involved, such as your anesthesiologist, are in network.

Even when you understand in advance the limits of your coverage, claims are sometimes denied. Your insurance company is required to provide an Explanation of Benefit, called an EOB, for each claim reviewed. The EOB outlines the amount paid by your insurance, your required contribution and, if not paying, the reasons for denial. It's important to read every EOB to make sure your claim has been properly paid and if not, the reasons for the denial.

When a claim is denied, your first step should be to call the insurance company to discuss. There are many reasons a claim may be denied ̶ often the insurance company just needs more documentation from your doctor's office to approve. Sometimes claims are denied for administrative reasons that are easy to fix. Make sure to keep track of every call or letter, writing down the date and who you spoke with at your insurance company.

Know Your Rights

If you do owe for a claim that was denied, or you feel your insurance company paid an improper amount, you have the right to appeal. You will receive written notice about how to appeal. Be sure to read them and note what the deadlines are, as they are very strict.

paper workHealth plans and insurance companies have to tell you very specifically why they've decided to deny a claim. You also have the right to request a full copy of your insurance file prior to the appeal to see how they reached their decision. This includes the claim reviewer's notes, reports of doctors who reviewed your claim and all other relevant documents.

Often the first appeal is submitted through your doctor's office so be sure to talk to your medical team. In your written appeal, document the reasons you disagree with the insurance company and always include medical records and a letter from your treating doctor. Your insurance company must conduct a full and fair review of its decision and, if urgent, they must expedite this process.

If your insurance company denies the appeal, you can request an external review. This means that independent medical professionals with no financial stake in the claim make the decision. If the external reviewer overturns your insurer's denial, your insurer must give you the payments or services you requested in your claim. If you believe your insurance company is acting improperly or in violation of the policy terms, you may also file a complaint with the New York Department of Financial Services or, if not in New York, with your state insurance department.

The good news is that many denied claims that are appealed or sent for an external review are finally allowed coverage. If you draw on all the resources available to you, and have adequate medical support for your claim, you stand a good chance of having your claim paid.

Here are some resources in New York State to assist you with health insurance disputes or questions:

The NY Health Plan Marketplace Consumer Assistance Line: 1.855.355.5777 or nationally, https://www.healthcare.gov/

New York Department of Financial Services
Consumer Hotline: (800) 342-3736 (Monday through Friday, 8:30 AM to 4:30 PM).
Local calls can be made to (212) 480-6400.
(The website has a link to file a complaint and they are often very helpful in resolving issues with your insurer.)

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