Help After a Medical Necessity Denial
Health insurance companies generally require that you prove that your proposed treatment is medically necessary. As such, health insurance companies often review and deny a payment for a service, procedure, or treatment because they deem it not to be so.
On top of potentially preventing you from receiving the care and treatment you need, this possibility is also a concern because many insurance companies employ teams of people whose sole job is to look for reasons to deny a person’s claim. It does not matter what type of health insurance plan you are covered by—if you are denied coverage for a prescription, procedure, service, or diagnostic test, it could have a serious impact on your health.
Rather than just accepting a denial, though, you have the right to appeal your insurer’s decision. Unfortunately, many people don’t understand this right. A study published in September 2023 found 69% of health insurance policyholders who received a denial in the past year didn’t know they had a right to appeal and 85% of them never filed an appeal.
After conducting a thorough investigation and review of your policy and applicable laws and regulations, a Los Angeles medical necessity denial appeals lawyer could help guide you through the internal and external appeals process. In addition, a health insurance denial attorney could help file a lawsuit to recover any out-of-pocket expenses you may have incurred because your health insurance company denied your claim.
Why Los Angeles Medical Necessity Claims Are Denied
Medical necessity claims are denied in Los Angeles for numerous reasons. Many of these denials could potentially be avoided if the insurance carrier was more thorough when reviewing the claim. For example, according to the United States Government Accountability Office, some claims are denied simply due to a clerical error or the wrong billing code. Others may be denied because the insurer claimed that the insured did not provide enough medical information to establish a necessity. Regardless of the reason, the policyholder generally can appeal the decision. If a person’s medical benefits were denied, they can work with an attorney who can help them pursue Los Angeles Medical necessity denial appeal.
Legal Obligations of Insurance Carriers
For group health plans that are subject to ERISA, health insurance carriers have several obligations to their insureds. One of these obligations is to provide timely information on the acceptance or denial of a claim. Another is to have an appeals process in place that includes a full and fair review of the claim. In accordance with the law, the insurance carrier must provide the following for a full and fair review:
• At least 180 days to file an appeal after receiving the notification of a Los Angeles medical necessity denial
• The ability to add records, written comments, or other related information to their claim file
• Free and reasonable access to copies of all documents and records related to the claim
• Consideration of all information submitted for the claim, regardless of whether the information was originally submitted or submitted with an appeal
• A review that is done by a neutral party
• Identification of any medical experts who reviewed the initial claim or appeal and provided advice to the insurance carrier
California law imposes similar requirements upon insurers of individual or family health plan members who it has denied a claim for coverage. Those who feel their initial claim or appeal was not handled in accordance with these laws should consult with a Los Angeles medical necessity denial lawyer. The lawyer can review all the claim records to help ensure the insurance company met all of its obligations.
Navigating an Internal Appeal
If an insurance company denies a course of treatment because of a lack of medical necessity, the first course of action is typically to go through an internal appeals process. If denying coverage, insurance companies must provide insured individuals with a denial letter which includes how to begin the internal appeals process. Understand more about submitting your appeal by downloading our eBook.
In most cases, a claimant would need to provide a written statement by their doctor explaining why the denial was improper. In other words, explaining in more detail why the insured needs the procedure, medication, or medical device in question. Indeed, collecting medical evidence to support why a course of treatment is medically necessary is generally critical to a successful appeal.
In addition to supporting an internal appeal with sufficient evidence and support, it is also important to note that an appeal must be filed within 180 days of receiving a denial notice. A Los Angeles medical necessity denial appeals lawyer could help denied policyholders ensure they file their appeal within this deadline.
How to Increase Your Chances of a Successful Appeal
There are several steps you can take to optimize your appeal including those below:
- Do your homework and include details. Get familiar with your insurance company’s appeal process and act promptly. Include all necessary information in your appeal such as the date of service, your details (your claim number, insurance ID, date of birth), and so on.
- Write about the reason for the denial. Remember, it might be something that is easily rectified such as a coding error or missing information.
- Be specific, detailed and succinct. Explain why the treatment or medication is medically necessary. Include data that supports medical necessity such as a letter from your doctor, lab results, medical records, etc. Explain how receiving this treatment will alter your health and thus your life.
- Collect data from independent 3rd party professional societies or associations. What you are asking for might be the standard of care for treating your health concern. It is not uncommon for certain insurance companies to deny what others say is medically necessary simply because their internal policies are not up-to-date with the latest medical information.
- Maintain records. Write down every encounter you have with your health insurance company, doctors, facilities, and others. Include the name of the person you spoke with, the date, what was discussed, what they said would happen next, and so on. Ask them about next steps and if you need to do something else or if they will reach out to you. Keep a copy of all letters, documents, proof of what you submitted, forms, and so on. You should be able to create a timeline of exactly what happened and when.
Applying for an Independent Medical Review
In 2001, the California state legislature created the Independent Medical Review Program. During an independent medical review, a medical professional determines whether an insurance company had a basis for denying a procedure as not medically necessary by examining medical records, professional standards, and their own expertise.
If the Independent Medical Review determines that the insurance company acted improperly, they would work through one of two regulatory bodies in the state of California to issue a written decision in an effort to compel the insurance company to change its decision: the California Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI).
The DMHC manages and oversees all health care plans, while the CDI governs insurance policies. It is critical to identify which regulatory agency to contact and to work with before pursuing an appeal. We also recommend that you speak with a qualified health insurance denial attorney before you file an IMR. The reason is that IMR decisions are very difficult to overturn and the attorney may recommend you follow a different path instead of the IMR. In addition, your insurance policy may outline a specific appeals process after an internal denial. For example, Medicare Advantage plans define one process and ERISA plans define a different process.
Filing Suit with a Los Angeles Medical Necessity Denial Appeals Attorney’s Help
While the internal review process and external appeals can result in the insurance company changing its decision, in some cases the only way to secure coverage is to file a lawsuit. If you or a loved one had a claim denied because of lack of medical necessity, contact a Los Angeles medical necessity denial appeals lawyer today to determine what options may be suited to your circumstances. An attorney can help you work to get your medical necessity denial overturned. This attorney is familiar with what it takes to make an insurance appeal more successful and can assist you through every step of this sometimes confusing and arduous process. Call today to learn how an attorney can help you.