Claim Denied!

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 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. If your initial request for authorization is denied, contact our office for support.
  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. For tips on preparing your appeal, see our blog on Preparing for a Long Term Disability Insurance Benefits Appeal.

For more on insurance denials, see When insurers don't pay for surgery.

In our experience, a common problem is the denial of authorizations for health procedures – for example, back surgeries. Many of our clients come to us when their insurance company has denied authorization for a medically necessary back surgery, which leaves them in pain and without the opportunity for treatment and healing. Unfortunately, it is the rare individual that can afford to pay out of pocket for this procedure. We have successfully argued that such treatment is not investigational, as claimed by the insurance company, but rather a medically appropriate and necessary treatment, accepted as proven and effective within the medical community, and utilizes FDA approved devices.

If you have experienced a procedure related insurance denial, please do not hesitate to contact our office for a no-cost consultation.

We understand, and we can help.
www.kantorlaw.net (800) 446-7529

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