Can my Doctor Appeal a Denied Insurance Claim?
If you have had a health insurance claim denied, there are steps you can take to correct the problem. In many cases, however, you will have to enlist the help of your healthcare provider. Physicians are typically willing to work with patients on denied insurance claims for several reasons.
First, most denied insurance claims stem from an error in coding or filing the claim and not because the services performed were not covered. Most physicians are aware of non-covered services denied routinely by major healthcare insurance companies and will be quick to explain to patients that the coverage they have does not provide for those services. Also, healthcare providers have to deal directly with patients and are not usually satisfied until the patient’s claim has been paid. Finally, doctors and other healthcare professionals risk losing the fee for the service if the insurance company will not pay as many people do not have the cash to pay for expensive treatments.
What are the First Steps to Appealing a Denied Insurance Claim?
You are usually the first line of defense in a denied insurance claim appeal rather than your physician. It usually takes only a single phone call if the error was made on the part of the insurance company rather than the provider to straighten out the problem. However, if the problem stems from inaccurate billing or coding, you will have to talk to your physician’s office in order to get the claim approved in most cases.
Call your insurance company first and determine exactly why the claim was denied. If the denial was due to inaccurate coding, record the information given to you by the insurance company then call your doctor’s office. Speak to the manager in charge of billing and explain the error in the code. In most cases, the office will immediately submit a new bill and often this claim will be paid quickly.
What Happens if the Problem is Not Coding?
Although inaccurate coding accounts for the majority of denied claims, there are other situations in which a health insurance company will deny a claim. For example, your doctor may have requested a test that the insurance company did not approve, or the insurance company may have standard testing orders that provide for a different test to be performed before the test your doctor ordered. In these cases, your physician can still appeal the claim, but the procedure will be different than that of simply correcting an inaccurate claim submission.
Most health insurance companies provide what is called a Letter of Medical Necessity form that can be filled out by a physician and submitted to the insurance company as proof that your procedure or test was medically necessary. This letter does not a guarantee that the insurance company will pay your claim, but it is usually the first step in filing a formal appeal of a claim denial. The insurance company wants your doctor to give a valid medical reason for ordering the test or procedure and your doctor will have to provide that information in the letter. Your physician should include any medical information that supports the necessity of the test, procedure, medication, or whatever has been denied by the claim. If your physician does not have an appeal letter form, your insurance company will often provide one in a preferred format to be used for claim appeals.
Your doctor may also file an appeal for a partial denial of services. This occurs when an insurance company approves part but not all of a procedure.
For example, if your doctor orders a CT scan of your entire abdomen, but the insurance company only approves the lower portion of the abdomen, the doctor has two choices. He or she can file an appeal to address the reasons for needing the entire abdomen scanned; this would be an appropriate choice if the situation was urgent and your doctor needed a larger view of the abdomen to make a diagnosis. The second possible strategy is to perform the truncated CT scan and then, if the results are not satisfactory, use this information to file a second claim for the complete scan. This would be an appropriate way to handle a non-threatening case, or one in which the doctor was merely ruling out unlikely conditions and did not feel a sense of urgency in running the entire scan. The procedure for appealing these types of situations is similar to that of appealing a completely denied claim; the doctor should write a detailed letter explaining the medical reasons for the test’s necessity.
If the insurance company insists that your claim is not covered under your policy, you can next file a grievance. Your doctor’s letter may help bolster your case, but be aware that many grievances are still denied coverage. Most insurance companies provide for arbitration or mediation in the case of a grievance rather than a lawsuit being filed, so check your policy or your plan’s website for specific grievance procedures. Be prepared to wait some time for a resolution to your case, as grievances often take many weeks to be heard by an arbitrator.
Personal health insurance is a necessity in today’s world but there are no laws which say having a claim paid must be easy. Anyone with health insurance must always read their policy in full and understand the terms of coverage along with the process for disputing a claim well before the time comes when a claim is denied.