San Jose Health Insurance Denial Attorney
Like many California cities, San Jose offers many parks and outdoor activities, along with the popular San Jose electric light tower and the Tech Museum of Innovation. Residents of San Jose, while enjoying their beautiful, diverse city, have the same issues with denied health insurance claims as others across the United States. Having the highly skilled San Jose health insurance denial attorney, Scott Glovsky in your corner can truly make a difference in the outcome of your claim denial.
What Are the Reasons Your Health Insurance Claim Could Be Denied?
According to Sift Healthcare, at least 9 percent of hospital claims are initially denied—to the tune of $262 billion annually. The average rate for health insurance denials for all healthcare providers is between 5-10 percent, and for Medicare and Medicaid, it is 10 percent or higher Many denied healthcare claims could have been prevented if the reason for the denial was something relatively simple like omitted information, incorrect data, coding errors, or patient eligibility issues. Healthcare claims are also denied for such things as:
- Inaccurate enrollment files
- Treatments with conflicting clinical protocols like sepsis or malnutrition
- Site of service exclusions
- Out-of-network healthcare provider
- Excluded service
- Above usual and customary charges
- Experimental treatment
- Treatment is not medically necessary
- Observation status or short-stay denials
- Experimental medication
What Should You Do if Your Health Claim is Denied?
If your healthcare claim is denied, you can appeal the decision. Your first step will be an internal appeal. This is the step where you ask your insurer to conduct a full and fair review of its adverse decision. To appeal your denial, you must do so within 30 days of receiving the denial letter from the insurer. Before filing your appeal, you should review your determination letter so you will know why your claim was denied. Collect all pertinent documents, including your insurance policy and the insurer’s medical necessity criteria. If you need additional documentation, contact your insurance company as well as your healthcare provider who can provide a letter explaining why the treatment or prescription drug is medically necessary.
You will submit your internal appeal in a timely manner or request an expedited internal appeal if waiting 30 days would seriously jeopardize your health, life, or ability to regain function. The internal appeals process should result in a decision within 30 days if you are requesting prior authorization, within 60 days if you already received medical services but are waiting for reimbursement, or within 72 hours if your case is urgent. If the internal review results in a negative decision, you can then file an external review, which is an independent third-party review.
Your request for an independent external review must be submitted within six months from the time you received the last determination letter from your insurer. If the decision is still unfavorable, you can file a complaint, and, potentially, a lawsuit against your insurer. The rules and timeframes for your appeals can be complex; Attorney Scott Glovsky helps people in your situation every single day and can speak to you about your health insurance denial.
Which Insurance Companies are Known to Deny Treatments?
Although any insurer can deny your health insurance claim, some insurers are more likely to do so than others. Medicare and Medicaid is likely to deny a claim, and those who depend on the ACA for their insurance are more likely to get an insurance denial than those who obtain their insurance through their employer. That being said, any insurer may do its best to deny a claim in order to increase its financial bottom line. Some of the insurers who deny claims for those insured in the state of California include:
What if My Insurer Won’t Pay for an Expensive Prescription Drug That I Need?
According to NPR, while the majority of Americans have health insurance that includes prescription drug coverage, this coverage doesn’t cover a prescribed drug for more than one-third of all adults across all income levels, at least once a year. While this is most common among lower-income adults (49 percent), it also occurs for those who are considered middle-income and high-income. Nearly half of all those whose insurance company denies coverage for a prescription drug say they simply don’t fill the prescription.
In some cases, your insurer may require that you try different (cheaper) versions of the drug before it will pay, but in others, you may simply receive an insurance denial for the drug. You should never give up on a prescription you need, rather you should speak to attorney Scott Glovsky who can help you file an appeal and get the prescription drug treatment you need for your health. Don’t wait, and don’t do without a drug you need.
When Should I Contact a Health Insurance Denial Attorney?
The sooner you contact a health insurance denial attorney from the Law Offices of Scott Glovsky, the better able Scott will be to help you. Appeals are full of specific deadlines, and the paperwork must be completely and correctly filled out. At a time when you may not be feeling your best, engaging in an appeal could feel overwhelming—just too much for you to deal with. The good news is you don’t have to deal with it. Scott will help ensure that your appeal is properly filed in a timely manner and is ready to fight for your rights.
How San Jose Health Insurance Denial Attorney Scott Glovsky Can Help
Having a knowledgeable health insurance denial attorney from the Law Offices of Scott Glovsky is your best chance for a positive outcome to your health claim denial. Attorney Scott Glovsky is nationally recognized as an advocate for the rights of insured policyholders. Scott can help you navigate a healthcare claim denial, always addressing injustice on your behalf. Contact the Law Offices of Scott Glovsky to discuss how you can get the medical treatment you need and deserve.
