If your insurance company denied a claim for the medical services you received, it’s critical to take action — ignoring a denial can result in a bill going into collections and adversely affecting your credit. However, many people wrongfully assume that if their insurance company issues a denial, they are automatically responsible for a costly bill. This is not always the case. There are several measures a patient can take if they’ve received a denial, including going through the insurance claim denial appeal process.

Find Out Why Your Claim Was Denied

The first thing to do when you receive a denial is find out exactly why the services were denied. Explanation of Benefits (EOBs) typically contain a footnote describing the reason. However, these footnotes often lack specificity. In some cases, they may even be incorrect. It’s best to call the insurance company and allow a representative to explain precisely why your claim was denied. Depending on the reason, you may be able to handle the appeal on your own, or hire a medical bill dispute advocate to help.

Correcting an Insurance Claim 

If your claim was denied due to an administrative issue such as a coordination of benefits, you may be able to correct the situation yourself. These kinds of mistakes often arise when a patient has a temporary overlap in insurance coverage, usually due to a job change. If a claim was denied simply because a provider unknowingly submitted it to your previous carrier, your provider can appeal by explaining this to the insurance company and providing proof of timely filing for the original claim.

Appealing Out-of-Network Treatment Denials

Appeals may be necessary for out-of-network care. Although in-network providers can submit an appeal for you, an out-of-network doctor cannot without your assigning your appeal rights to that provider. In these circumstances, you might request a letter from that provider indicating the necessity for the treatment and covering any other clinical discussion. Since these appeals often require significant clinical support and argument, it may be helpful to work with an experienced medical bill dispute advocate who is familiar with the process and knows what documentation to provide.

Medical Necessity Denials

If your insurance claim was denied based upon lack of medical necessity or for it being an experimental/investigational treatment, and all internal appeals have been exhausted, you can escalate your dispute through an external appeal. This means that an organization of independent doctors will peer review your case and determine whether the insurance company should have processed the claim under your policy.

Appealing COVID-19 Insurance Denials

If you were issued a denial for your COVID-19 medical bill, contact your provider to see how they will be handling it. Many mistakes continue to be made in the way insurance companies are processing COVID-19 medical bills resulting in patients being charged for services that should have been covered. Some providers may be willing to fight a denial or COVID-19 overcharges for you — others may put the responsibility on their patients to dispute the processing of the claim directly with the insurance company.

The Insurance Denial Appeal Process

An insurance denial appeal case must be handled systematically and pragmatically. No matter how well written, insurance companies will not respond any more favorably to an emotional appeal. The focus of an appeal should be solely on the facts concerning why your appeal should be granted, citing references and any correlating documentation.

Often, insurance companies uphold their original decisions and deny first appeals outright to avoid making payment. A second level appeal may be given more attention. However, at the second level, you cannot merely re-state the argument in your first appeal. Rather, you must provide further documentation to support your position such as medical journal peer review articles or doctors’ letters.

There are strict deadlines associated with filing appeals. These deadlines will vary by insurer and policy. For a first level appeal, most policies allow 180 days from the date of the EOB denial to file the appeal. A second level appeal usually needs to be filed within 60 days of the first appeal denial. Sending in a late appeal can result in your waiving the right to file one.

Request That a Specialist Review Your Appeal

Regardless of the appeal level, it’s crucial to request a doctor in the specialty that you were treated be on your review board. For example, if your claim denial concerns neurology, you should request that a neurologist review the appeal. If not specifically requested, a doctor outside the specialty will likely be the one to make a determination on your claim.

How Systemedic Can Help With Your Insurance Claim Denial Appeal

If you’ve received an insurance claim denial, an experienced medical bill dispute advocate can help. Systemedic has been providing help with medical bills for over 30 years and knows what it takes to quickly and effectively negotiate even the most complicated medical bills.

Offering a fee-based service for those looking to dispute their medical bills, our medical bill dispute advocates are skilled in navigating the insurance maze and will not take “no” for an answer. Contact us for a consultation.

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