Health Insurance Denial Attorney Serving San Francisco
While those who live in San Francisco enjoy their beautiful surroundings and high quality of life, they nonetheless experience health insurance denials like those across the U.S. Having a knowledgeable San Francisco health insurance denial attorney like Scott Glovsky on your side can make all the difference in the outcome of your claim denial.
What Are the Reasons Your Health Insurance Claim Could Be Denied?
Whether you are insured through your employer, through the Affordable Care Act, or through Medicare or Medicaid, you may have experienced health insurance denials. Hospitals report a claim denial rate of about 10 percent, while those who obtain their insurance through the Affordable Care Act have a higher rate of insurance claim denials—about 18 percent.
In fact, of the more than 230 million claims submitted in 2020 through the ACA, 42 million claims were denied, with one out of five of those denied claims for behavioral health services. Claims are often denied for issues that can be corrected, such as incomplete paperwork, missing or incorrect information, coding errors, or patient eligibility issues. The issues that are more difficult to fix, and are often not valid denials include:
- Out-of-network healthcare provider
- Failure to obtain prior authorization
- Experimental treatment or medication
- Site of service exclusions
- Treatment is not medically necessary
- Inaccurate enrollment files
- Excluded service
- Above usual and customary cost
- A diagnosis of sepsis, malnutrition, or another treatment with conflicting clinical protocols
- Observations status or short stay denials
What Should You Do if Your Health Claim is Denied?
If your health claim is denied, it can be extremely beneficial for you to contact an experienced health insurance denial attorney from the Law Offices of Scott Glovsky. Appeals can be complex, and a single missed deadline or incorrectly filled out form can make the difference in whether your claim is ultimately approved. You have a couple of avenues for appealing the adverse decision of your insurers. You will start with an internal appeal, which must be filed within 30 days of the time you received your denial letter. Make sure your denial letter explicitly states why your claim is being denied. If your insurer is stating the procedure or treatment is not medically necessary, it can be helpful to obtain a letter from your healthcare provider stating all the reasons why the procedure or treatment is medically necessary. The same is true if the healthcare provider states the procedure or treatment is experimental or investigational.
If your case is urgent—meaning that waiting 30 days for a response from your insurer would seriously jeopardize your health, life, or ability to regain function—you can ask for an expedited appeal. Your insurer must provide you with a decision on your appeal within 30 days for a prior authorization, or within 60 days if you have already received the treatment or procedure and are waiting for reimbursement. You should receive a decision within 72 hours if your case is urgent.
You can file an external appeal—an independent review from a third party. If the decision is still unfavorable, you can file a complaint, and, potentially, a lawsuit against your insurer. Attorney Scott Glovsky can help you with your appeal, your complaint, and even a lawsuit against your insurer. This can take much of the burden from your shoulders, allowing you to concentrate on your health and your future.
Which Insurance Companies are Known to Deny Treatments?
Although any insurer can deny your medical claim, some insurers are more likely to do so than others. For California residents, the following healthcare insurers may have denied their claim:
No matter which insurer denied your claim, your chances of a successful appeal increase exponentially when you have an experienced health insurance denial attorney from the Law Offices of Scott Glovsky by your side.
How Do I Find Out Why My Health Insurance Claim Was Denied?
Your insurer is required, under the law, to give you an explanation as to why your claim was denied. The insurance company should have sent you a letter of denial that clearly stated why your claim was denied. If the reason for the denial is a relatively simple one that you can easily correct, you can do so, then re-submit the claim. If the denial states that the treatment is not medically necessary, or is experimental or investigational, you may need to file an appeal with your insurer. It can be helpful to have a highly skilled health insurance denial attorney from the Law Offices of Scott Glovsky help you with your appeal, giving you the best chance of a reversal.
What if My Insurer Still Refuses to Pay My Claim After It Is Approved in an External Appeal?
If your external appeal by a third party results in a decision in your favor, but your insurance company is still refusing to pay your claim, your health insurance denial attorney may advise filing a lawsuit against your insurer. If your insurer is operating in bad faith and is refusing to pay a claim that an external review approved, then it is not following the law. Having a strong legal advocate like attorney Scott Glovsky can take the burden from your shoulders, giving you someone in your corner who will fight for you, your rights, and your future.
How San Francisco Health Insurance Denial Attorney Scott Glovsky Can Help
Health insurance denial attorney Scott Glovsky has been helping people just like you for more than two decades. Scott understands that you may be feeling overwhelmed, and unable to cope with the appeal process. If you are busy—and who is not in today’s world—it can be a huge relief for this burden to be taken from you and handled by a legal professional who is committed to fighting for you and the treatment you need. Contact the Law Offices of Scott Glovsky today for the help you need and deserve.