In 2023, nearly one in five in-network health insurance claims from plans sold on Healthcare.gov were denied, and out-of-network claims faced even higher denial rates, with more than a third turned down.
However, consumers have the right to appeal these decisions.
First, call your insurance company, as a simple billing mistake or paperwork error might be the issue.
"Mistakes can and do happen at multiple points in the claim-filing or pre-authorization process, and they are often relatively easy to fix, once you identify them," said a representative from Consumer Reports.
If the denial was not a mistake, you have the right to appeal. Speak directly to the reviewer who made the decision and get a clear explanation for why your claim was denied. This information is crucial for filing a formal appeal stating your disagreement with the decision.
"You're going to ask your doctor to help to write a letter that explains the necessity for the procedure and include as many supporting documents as possible – like your medical records and treatment studies, and any communication with the insurance company," Lisa Gill said.
Doctors are accustomed to this process, so do not hesitate to ask for their assistance. The next step involves waiting, which could take 30 days or longer for an answer. If immediate treatment is necessary, request an expedited review.
Gill added, "So, if you get a letter that the insurer is still choosing to deny the claim, both Medicare and the private insurance are required by law to give you the reason in writing and tell you how to appeal the decision for review by an independent third party."
If your insurance is through work, consider asking your human resources department for help. If Medicare denied your claim, legal assistance might be necessary to present your case before a judge.
Additionally, if you receive a surprise medical bill, request an itemized bill and question every charge before making a payment.
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