Handling Insurance Appeals

Your claim has been…  denied.

The thought of reading that sentence after undergoing a medical procedure is enough to send most people into a panic. A hundred questions flood your mind. What happened? Why was my claim denied? What can I do about it?

Before anything else, take a deep breath. Just because you receive this initial response, doesn’t always mean you’re out of luck. You have options. One of those options is to appeal the insurance plan’s decision to deny your claim.

It’s worth stating that your insurance plan likely isn’t just looking to stress you out. There could be a handful of reasons that can be dealt with. One reason that claims can be denied is because of how it was coded. For example, say they diagnosed osteoarthritis and then mistakenly assigned a procedure code associated with heart surgery. That could result in a denial because, obviously, heart surgery probably isn’t a treatment for osteoarthritis. It could be a matter of simply talking to your doctor’s billing office and explaining the situation. They can help you straighten things out.

Another reason your claim may be denied is if a prior authorization was required and you didn’t receive one. It’s a good practice before any procedure to contact your insurance provider to ensure you know whether or not you need a prior authorization. Make sure to write down the name of the person you spoke to and a reference number if applicable. This will be very helpful should your claim be denied based on lack of prior authorization. This is something your doctor’s billing office can assist you with as well.

One of the most important things you can do is have a thorough understanding of your condition and treatment plan. You should be able to clearly explain what your diagnosis was, the previous treatments you’ve tried, and why your doctor recommended the procedure in question. It’s also good to be familiar with the type of insurance you have and the basics that are covered. All this can be obtained by speaking with your doctor and his billing office.

If you’re facing a claim denial, or are simply trying to understand the topic, a great resource for navigating insurance appeals can be found at the Patient Advocate Foundation, specifically by clicking here.

Remember, you’re not alone. Your doctor and his staff are there to help you along the way. And, most likely your insurance provider will be happy to assist you as well.