Has Your Claim Been Denied?
Perhaps your insurance company has refused to pay for a treatment, test, service, or prescription drug you may desperately need for your health. If your health insurance company is violating the terms of your insurance policy, you may have a legitimate lawsuit against it. Your insurance company may also consistently fail to pay your claims promptly or may underpay your claims.
There are laws designed to protect consumers in the state of California and across the nation. It’s not uncommon for policyholders to sue their healthcare insurers for denial of a claim, mainly when the claim is for a service that is crucial to their health and future or the health and future of a loved one. If you have received a denial for a healthcare claim, Attorney Scott Glovsky can help! The Law Offices of Scott Glovsky are highly knowledgeable, with years of experience helping others just like you.
Why Are Healthcare Claims Often Denied?
Your attorney will help determine exactly why your insurer denied your claim, but the most common reasons for healthcare denials include:
- Errors in paperwork, omissions, or mix-ups
- Your healthcare provider is questioning whether your procedure, test, or prescription drug is medically necessary
- Your healthcare provider wants you to try a less expensive option before it pays for the requested service, medication or treatment (known as step therapy or “fail first”)
- Your plan doesn’t cover the service requested (such as cosmetic surgery)
- Your healthcare provider claims you used an out-of-network provider
- You failed to obtain pre-authorization for a procedure or test (non-emergency)
What Can I Do if My Health Insurance Claim is Denied?
If your health insurance claim has been denied, you have multiple options. If you are unsure of what you need to do or the process for any of these solutions, speaking to a knowledgeable health insurance claim denial attorney from the Law Offices of Scott Glovsky can be extremely helpful. Some possible solutions to a claim denial include:
- Before doing anything else, you must understand why your claim was denied. Your insurer must provide you, in writing, the reason for the denial, which could be an incorrect or duplicate claim, lack of medical necessity, a procedure deemed experimental or investigational, or lack of supporting documentation. Your claim might also be denied because you are not eligible for the service or benefit under the terms of your plan. As an example, cosmetic surgery is rarely a covered service under most healthcare plans.
- Begin the process of an internal appeal, which involves a written request to your insurer that explains why you believe your claim should be approved. You may also submit a letter from your doctor explaining all the reasons the treatment is necessary for your health. You might also provide medical literature supporting your denied treatment’s effectiveness.
- You will then resubmit your original claim, along with the appeal paperwork and any supporting documentation. If there is a simple error on your original claim that you have since resolved, your claim will be approved. If the insurance company is swayed by your doctor’s letter or your explanation of why the treatment is necessary, your claim will be approved. Otherwise, the insurer will once again deny your claim for treatment or services. During an internal appeal you have six months from the day you learn your claim was denied to then file an appeal. Your insurer then has a set amount of time to respond to your appeal. If waiting for an extended amount of time could cause more harm, you can file an expedited appeal.
- If your internal appeal is denied, you can file an external appeal before a neutral third party. During an external appeal, you are asking an independent entity to look at all the facts and make a decision on your claim. You usually have four months from the date you learn your internal appeal was denied to file an external appeal. An expedited external appeal process can also be used under certain circumstances.
Your process for filing an internal or external appeal will depend to some extent on the type of medical plan you have and your insurer. You may have an individual plan purchased through your state’s marketplace or purchased directly from an insurance company. You could have a funded plan, which is purchased by your employer, or you could have a self-funded plan where your employer directly pays for your healthcare costs but usually hires an insurance company to administer the plan. You might also have Medicare or Medi-Cal (AKA Medicaid). Regardless of how you get your healthcare insurance, attorney Scott Glovsky is ready to help you turn a denial into an approval whenever possible.
How Often Are Health Insurance Claims Denied?
The rate at which health insurance claims are denied can depend heavily on the health insurance company and the type of healthcare plan (PPO, HMO, Managed Care, Medicare, Medicare Advantage, Medicaid). The type of medical care requested—whether surgical, medication, or treatment—can also affect the rate of claim denial. According to the Experian State of Claims 2022, 42 percent of providers said the number of denials had increased. Two years later, 77 percent of providers said the number of denials had increased. The time it took medical professionals to get reimbursed also increased from 2022 to 2024. Just a few years ago, the cost of denied claims for healthcare companies was more than $260 billion dollars a year. You can assume that number is significantly higher now.
According to Stat News, at least 15 percent of all claims submitted are initially denied, with higher rates among Medicare Advantage and Medicaid Managed Care plans. These denials included services that had been preapproved via the prior authorization process, however, treatments that cost more than $14,000 were much more likely to be denied. More than half of the claims that were initially denied were eventually paid when the member appealed the denial. Private payers tended to overturn denials at a higher rate than Medicare and Medicaid, but the appeal process comes at a cost for healthcare providers. Healthcare providers are believed to spend almost $20 billion a year on claims reviews; over half of that $20 billion is wasted arguing over claims that should have been paid from the start.
Patients who have denied claims may either not receive the services or treatments they need or could end up being liable for some or all of the costs. Almost half of all Americans say they have skipped or delayed follow-up care because they simply did not have the money to pay for it. More than half of all American bankruptcies are filed because of medical debt, so when insurers deny necessary treatments, there is a ripple effect from providers to patients, and even to how bankruptcies affect the U.S. economy. Since Medicare Advantage has a higher-than-average denial of claims, this is a key area of concern.
According to commonwealthfund.org, 45 percent of insured, working-age adults have received a medical bill or been charged a co-payment over the past year they thought was covered under their insurance plan. Less than half of these adults said they challenged the denial, most commonly because they were unaware of their right to do so. At least two out of every five who challenged a denial said the bill was ultimately eliminated. Almost 60 percent of these adults said their medical care was delayed as a result of a healthcare claim denial.
Can I Sue My Healthcare Insurance Company?
Healthcare insurers have obligations to their policyholders; they must abide by the policy’s terms, act in good faith, and avoid unfair trade practices. Healthcare is usually regulated at the state level. Health insurance companies should adequately and promptly investigate a claim, pay claims that meet the rules, approve or deny a claim within a reasonable timeframe, and give a detailed explanation for a claim denial. If you believe your healthcare claim was improperly denied, yet your healthcare insurance company refuses to budge, even after your appeal, your attorney may advise you to file a lawsuit. Your attorney can explain the types of damages available.
How Scott Glovsky Can Help
Once you speak to experienced attorney Scott Glovsky, he can tell you whether your health insurer acted in bad faith. If the answer to that question is yes, and Scott takes your case, he will fight to recover damages, such as pain and suffering, lost wages, emotional trauma, and more. It is crucial that you never sign paperwork from your health insurance company before speaking to the Law Offices of Scott Glovsky. Often, a health insurance company will try to mail you a check, reimbursing you for your healthcare premiums. This is an underhanded way to get out of paying the actual value of your damages. That’s why it is a good idea to speak with Scott before you cash the check. If you are facing a healthcare claim denial, contact Scott Glovsky today.