If your health insurance claim a surgery is denied, you need to challenge your insurer, rather than simply taking “No,” for an answer. That's because the majority of claims are “electronically adjudicated,” according to America's Health Insurance Plans research at AIHPresearch.com. Electronic adjudication means claims are processed electronically, with no manual intervention, using denial algorithms that look for ways to deny coverage.
Approximately 14 percent of claims are “pended,” meaning flagged for more information or investigation. The reasons given can be simple clerical errors such as duplicate claims and missing or inaccurate information. Reasons that are more complicated include services not covered, ineligible providers, experimental treatments and pre-existing health conditions. Around half of these claims will be “made clean,” with further information and processing. The remainder is simply denied coverage if there is no simple resolution.
Whether claims are denied just because they are not easy fixes, or if they are part of a more sinister “game of deny, delay and deceive,” as described by New York Attorney General Andrew Cuomo, there are things you can due to resolve your situation.
If you haven't undergone surgery already, and it's not an emergency, read your policy carefully to make sure you are covered beforehand. If you have any doubts, talk to your insurance company and get pre-approval. Don't just check that your treatment is covered, either. Make sure your chosen provider is eligible for coverage too and get a confirmation number from the representative for later reference.
Prepare your Appeal
If your insurance company denies coverage, check your policy to see how long you have to appeal the decision. Read the denial letter carefully and be sure you understand why coverage was denied. Take time to understand the appeals process outlined in your insurance policy. Remember that an insurance policy is a contract, meaning you must adhere to the rules laid out in the contract. If there is any part of the reason for denial or the appeals process you do not understand, make a phone call and ask a representative to explain it to you.
Make it clear to the representative that you are just trying to understand the process and have not yet decided if you will appeal, otherwise you will trigger a range of administrative procedures that could cause you other problems. Take note of the representative’s name, the date and the time you spoke.
If you are already having trouble getting help from your insurance company, consider contacting the patient Advocate Foundation (patientadvocate.org). They may be able to help you with specific information to help you challenge your insurer.
Carefully prepare your case, enlisting the help of your doctor and his or her billing department to secure medical opinions or other medical information needed to support your case. You have the right to have your appeal reviewed by a medical specialist, so make sure you insist this procedure is followed. This way, any denial will be based on medical opinions, not financial reasons.
Don't give up
If your appeal is denied, follow the process until you have exhausted the internal appeals process. If your coverage is still denied, check with your state insurance department. Find out if you have access to an external independent review, and how it can be initiated.
The good news is that around half of all denied claims that are appealed to the top are finally allowed coverage. If you draw on all the resources available to you, and have adequate medical support for your claim, you stand a good chance of having your claim paid.