Tips for reversing health insurance claim denials

Reversing health insurance denials

There's no way to know what percentage of health insurance claims are denied, as carriers are not required to report them. Some industry reports show claim denials can range anywhere from 17% to 30% or more, depending on the insurance company.

The murder of UnitedHealthcare CEO Brian Thompson, and the suspicion that it may have been over insurance claim denials, is shining a new spotlight on the issue.

There's no way to know what percentage of health insurance claims are denied, as carriers are not required to report them.

Some industry reports show claim denials can range anywhere from 17% to 30% or more, depending on the insurance company.

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Few patients appeal denials. A Kaiser Family Foundation report found fewer than one percent of Affordable Care Act patients appealed claim denials in 2021, for example. Yet, about 40% of those appeals were successful.

Patient advocate Adria Gross of MedWise Insurance Advocacy says a denial can be devastating. It can prevent some patients from getting care they need, and leave others with serious medical debt despite having paid insurance premiums.

"It seems to me, that we pay the money and if there’s any way they don’t have to pay the money, they’re going to do it," said patient advocate Adria Gross of MedWise Insurance Advocacy.

Gross says start by checking your policy. If you believe your claim should have been covered but has been denied, you have the right to appeal, often two or three times, depending on the insurance company.

Find the reason for the denial that's listed on your denial letter or call your insurer.

If it's listed as "not medically necessary," ask your care provider to write a letter outlining why you needed the treatment.

You may need to provide documentation or records supporting your claim. In some cases, you can submit peer-reviewed articles or treatment guidelines from recognized medical organizations.

"You have to get the medical records. Find out why you were placed in the hospital to begin with. And I recommend you have your doctor, or whoever took care of you, even your primary, write why you were in the hospital and needed the care," explains Gross.

Be sure to file appeals before deadlines, which are usually listed on denial letters or your explanation of benefits. Then send your appeal package to the insurer via certified mail so that you get a receipt that it was received.

And no matter what, says Gross, "Don’t ever give up. Fight for your rights. You pay for your insuance and you have a right to be covered by your policy."

You may want to seek help from a patient advocate, also known as a health advocate.

Two non-profits that can help are the National Patient Advocate Foundation, and the National Association of Healthcare Advocacy.

Other organizations that can help you find advocates include UMBRA and ACAP HealthWorks.

If your appeals are denied again, you can also file a complaint with the State Department of Insurance and the State Attorney General's Office.

Keep copies of all documentation and correspondence throughout the whole process.

You can also hire an attorney.

To help avoid a denial before treatment, verify with your insurer that your care provider is in-network, and get pre-authorization in writing before having any treatment or procedure.

Sullivan's Smart Sense Health Care