Have You Been Denied a Healthcare Service or Treatment? Call Scott Glovsky!
Being denied a service or treatment that your doctor believes you need for your health can be very discouraging. Navigating the appeals process can feel overwhelming when you may not be feeling well physically. At the Law Offices of Scott Glovsky, we truly care about you and your future. We are a small group of devoted lawyers and staff who go the extra mile to really know our clients and their stories. We promise our clients that we will care about them and their cause, we will listen to them, support them, be available and responsive to them, and always put their needs first. Scott Glovsky will be honest with you, always treating you with dignity and respect, and will fearlessly and boldly fight for your rights and your future.
About Health Net
Health Net is a managed health care company that was founded in 1985, and based in Woodland Hills, CA. Health Net was founded four decades ago, and today has more than 3,000 employees, 85,000 network providers, and more than three million members, or nearly one in twelve Californians. Health Net provides health plans for individuals, families, small and large businesses, those with Medicare, and those with Medi-Cal. Health Net also offers access to substance abuse programs, behavioral health services, employee assistance programs, and managed health care product related to prescription drugs. Health Net is a subsidiary of Centene Corporation, a Fortune 100 company that provides health coverage to more than twenty million Americans.
More people than ever rely on their health insurance to cover their medical expenses. The medical treatments covered by health insurance can range from simple medical check-ups to emergency surgeries and extensive rehabilitation services. Some insurance policies cover most, or all, of the expenses related to these services, but there are instances when an insurance company denies payment for medical treatment. However, reviews for Health net are not all that positive. Like many insurance companies, Health Net likely practices “delay, deny, underpay,” for many legitimate claims.
What are the “Typical” Coverage Denials from Health Insurance Providers Like Health Net?
Although there are many reasons your health insurance claim could be denied, some of these reasons are more common than others. If you are unsure why your insurance claim was denied, you could call your doctor, insurance company, or hospital as soon as you receive your Statement of Benefits to find out why your claim was denied. The most common reasons for denial of coverage include:
- Coding errors for a diagnosis or procedure
- Omissions of diagnosis or procedure
- Non-capture of tests or procedures
- Lack of prior authorization or pre-certification
- Incomplete insurance information
- Inaccurate insurance information
- In-network providers not used
- The filing time limit has passed
- Insufficient evidence of medical necessity
- Deductible not paid
- Co-pay not paid
- Patient portion not paid
Reasons Health Net Could Deny Your Claim
Insurance companies like Health Net often come up with a variety of reasons to deny treatment or a claim. Unfortunately, the primary reason for denial of claims is usually profit; insurance companies increase their profits by denying any claim they consider “questionable.” The most common reasons given by insurance companies like Health Net include:
- The patient used an out-of-network doctor or provider.
- Health Net considers the treatment to be medically unnecessary.
- The procedure in question is considered elective, or non-essential to the patient’s health.
- The insured failed to complete his or her application correctly or completely.
No matter why the company denies coverage for a treatment or procedure, they are required to provide a written explanation that includes information regarding how the denial can be appealed. Learn about how to appeal a health insurance denial by downloading our eBook. The state of California provides a means for those who have had their claim denied for appealing the decision; all insurers must maintain an internal appeals process, and if this process fails, there are other options for appealing a claim.
A Health Net health insurer denial lawyer like Scott Glovsky can help you appeal your denial of coverage. Whether your denial involves an outright denial of treatment or a refusal to reimburse already-received treatment, having a highly experienced health insurance denial attorney in your corner can help ensure enforcement of insurance policies.
Appealing a Health Net Denial of Coverage
The State of California requires that all insurers maintain their own internal appeals process for coverage denials. Health Net gives subscribers 60 days from the notice of their decision to file an appeal. The individual can either independently file the appeal or someone can file it on their behalf. If they appoint a representative to file the appeal, they must fill out the necessary paperwork giving the representative authority to act on their behalf.
Unfortunately, these appeals are rarely successful as the people who denied the claim the first time are usually the ones who process the appeal. However, if the insurer denies the appeal, the individual may have the right to take the appeal to an independent third-party for additional review, but this is not necessarily the best path. In some cases, it may make more sense to take the case directly to civil court instead.
Health insurance policies are contracts between subscribers and the insurance company, and the court may consider the denial of coverage a breach of contract on the part of the insurance company. If that is the case, they may order the insurance company to cover costs. A Los Angeles Health Net health insurance denial lawyer like Scott Glovsky can evaluate the claim and help the individual determine the way to proceed that fits your need.
FAQs Regarding Health Net Coverage Denials
If you have been denied healthcare coverage, you may have many questions, including:
What if my plan won’t pay for the care I think should be covered?
You can appeal internally, asking that your insurer reconsider the denial. If your request is still denied, you can ask for an independent, external review to help resolve the dispute. If you are in a job-based plan, you could be required to appeal to your plan a second time prior to requesting an external review. If the external reviewer says the claim must be paid, your health plan will have to cover it.
What is prior authorization?
In some cases, Health Net may require that you obtain prior authorization or approval before you can get certain healthcare services. If you obtained services without that authorization, even if those services are necessary, Health Net may refuse to pay for the treatment or service. Even in such a case, your attorney may be able to help you receive payment or reimbursement for your treatment or service.
What is the external review process?
If your internal review request is denied, you can file a written request for an external review. An external review will either uphold your insurer’s original denial decision or will decide in your favor. Your insurer is required by law to accept the decision of the external reviewer.
What types of denials can go to external review?
Any denial involving medical judgment where you or your provider may disagree with the health insurance plan can go to external review. Any denial involving a determination that a treatment is experimental can go to external review. If your insurer cancels your coverage, claiming you gave false or incomplete information on your original application, this decision can go to external review.
Fighting Back Against a Healthnet Denial
After having their claim denied for a medically necessary treatment or medication, many people feel a deep sense of despair and anger. Such feelings are normal, but it is important for policyholders to remember they may be able to fight back with the help of a Los Angeles Healthnet medical necessity denial lawyer.
The insurance company does not always have the last word, and if an insurer chooses to deny a claim for no logical reason, they should be held accountable for their actions. Depending on the nature of the case, an attorney may be able to help policyholders do the following:
- Carry out an in-depth investigation of the process and criteria an insurer uses to approve or deny a claim
- Thoroughly examine the details contained in the coverage policy
- Retain the services of other insurance professionals and physicians
- Hold the insurer responsible for any damages incurred by the policyholder
Often, when a claim is denied for no reason, the policyholder is left with a barrage of emotional scars and medical bills. In many cases, they may have to use their own funds to cover additional expenses. A skilled lawyer can help them recover these damages.
Medical Necessity Denials in Los Angeles
When a physician or medical professional deems a treatment “medically necessary,” the policyholder should submit a claim for treatment to the insurance company. If their insurance company offers coverage for the treatment, they should approve the claim.
Unfortunately, this does not always happen and insurance companies may attempt to refuse coverage for a treatment or medication they are contractually obligated to cover. Insurers often consult a team of their own doctors who will not have the opportunity to examine the patient themselves before denying a claim.
Sometimes, even when a claim is approved, the insurance company will only agree to cover a cheaper, often less effective, alternative. This is unfair, and when a person cannot receive the medical care they need there is a risk of death or further injury.
The Price of Cutting Costs
Many people forget insurance companies are businesses. Even though they provide an essential service to society, their ultimate goal is to generate profits and reduce operational costs. To do this, they may attempt to curb costs by denying certain policyholder claims.
Despite the consequences of such behavior, insurance companies are often willing to jeopardize the health of their policyholders and their own reputation to avoid paying for expensive treatments and medications. However, a Los Angeles Healthnet medical necessity denial lawyer can work to hold them accountable.
News Related to Health Net
In response to Governor Gavin Newsom’s declared state of emergency during the 2020 pandemic, Health Net has worked to ensure everyone knows what they can do to help protect themselves against COVID-19. Like most insurance companies, Health Net is waiving co-pays for medically necessary screenings and tests for COVID-19. That being said, if you find yourself being denied coverage for a medically necessary COVID-19 screening or test it is important that you contact a health insurance denial lawyer from the Law Offices of Scott Glovsky to ensure you receive the necessary treatment during the pandemic.
Nagler v. Health Net, Inc. et al. – Pasadena, CA, December 7, 2015 – The Law Offices of Scott Glovsky filed suit in Los Angeles Superior Court against Health Net of California and Cal Care for their failure to maintain an adequate network of providers and specialists for their insured. Specifically, the Law Offices of Scott Glovsky brought suit on behalf of Austin Nagler, a Health Net and Cal Care member and Los Angeles resident who alleges that he was unable to receive timely access to medically necessary but extremely complicated wrist and hand surgery because Health Net failed to maintain a network that contained a hand surgeon qualified to perform such a procedure. As a result, Austin alleges that he has suffered permanent injury to his wrist and hand which has greatly impacted his mobility and has left him unable to continue his work as a graphic designer.
How Scott Glovsky Can Help if You’ve Had a Coverage Denial
You are probably like most people in that you expect your health insurance will provide necessary payments for a medical emergency or will provide coverage should you fall ill. However, insurance companies like Health Net of California may engage in a variety of methods to deny coverage, thereby increasing their profits. Scott Glovsky is the Health Net health insurance denial lawyer you need in your corner when it comes time to fight the insurance company.
You may wonder what sets the Law Offices of Scott Glovsky apart from other California insurance denial lawyers. Scott has experience working on the other side, after working in large corporate law firms defending insurance companies in bad faith lawsuits. Scott Glovsky understands how insurance companies think and operate which allows him to always stay a step ahead. Eighty-five percent of Scott’s cases are referred to him by other attorneys who are aware of his insurance expertise, as well as his stellar reputation. Scott never takes on more clients than he can handle because he believes in personally devoting a tremendous amount of time and care to each client. Scott gets to know each client, their families, and the story behind their pain. In short, you will never be treated as just another client when you choose the Law Offices of Scott Glovsky.
Scott can file an appeal with the internal processes of Health Net, create a case before the state’s review board, or take your case to court to enforce a policy. If Health Net of California denied your health insurance claim, contact Scott Glovsky today to find out how we can help you during this difficult time. We want to make sure you get the treatment you need, while also making sure Health Net provides the coverage you were promised.