Santa Barbara Health Insurance Denial Attorney
Residents of Santa Barbara enjoy the climate and the beauty of their surroundings yet can still experience health insurance denials that can turn their lives upside down. Having an experienced Santa Barbara health insurance denial attorney like Scott Glovsky as your advocate can make a significant difference in the outcome of your claim denial.
What Are the Reasons Your Health Insurance Claim Could Be Denied?
Health insurance claims are denied for a variety of reasons. Some of these reasons are easily “fixable,” like missing or incorrect data, incomplete paperwork, coding errors, or patient eligibility mistakes. When you find out your claim has been denied for one of these reasons, you simply fix the mistake and re-submit the claim.
Other reasons your health care claim could be denied are more complex and can benefit from having a zealous health insurance denial attorney assisting you in getting the denial reversed. Often, these denials can make a life-changing difference to you—you may need a treatment or medication to get better or even to stay alive, yet your insurer may refuse to pay for the claim. The reasons you may be given for a health insurance claim denial include:
- Out-of-network healthcare provider
- Failure to obtain prior authorization
- Experimental treatment or medication
- Site of service exclusions
- Inaccurate enrollment files
- Treatment or medication is deemed not medically necessary
- A diagnosis of sepsis, malnutrition, or another treatment with conflicting clinical protocols
- Observations status or short stay denials
- Excluded service
- Above usual and customary cost
What Should You Do if Your Health Claim is Denied?
If your healthcare claim is denied, you do have options. You can first file an internal appeal with your insurer. If that claim is also denied, you can file an external, or third-party appeal through the external appeal process. You can ask your insurer to conduct a full and fair review of its decision, but the appeal must be filed within 30 days of the date of your denial letter. You will review your denial determination letter so you will know exactly why your claim was denied. Collect the necessary information to support your request for a reversal of the denial decision.
Your appeal can probably benefit from having a letter from your healthcare provider to show that your treatment or prescription drug is a medical necessity to help your health condition improve. If your condition is considered urgent, you can request an expedited internal appeal. Your case is considered urgent if waiting 30 days for the appeal decision would jeopardize your health, life, or ability to regain function.
If your insurer continues to deny your treatment or medication after you file an appeal, you can file an independent medical review or external review. An independent third party will review the decision by your insurer, taking the decision out of the insurer’s hands. However, we recommend that you speak with an experienced health insurance denial attorney before proceeding with an independent medical review. This attorney can help strategically direct the best path forward. If the decision is still unfavorable, you can file a complaint, and, potentially, a lawsuit against your insurer.
Which Insurance Companies are Known to Deny Treatments?
Although any insurer can deny a healthcare claim—and all will do so when they can get by with it—some insurers may be more likely to deny a claim than others. Among those with insurance through Healthcare.gov, certain insurers have rates as high as 80 percent for claim denials according to a 2022 report from Kaiser Family Foundation.
Under the ACA, Marketplace payers must report claims denial data; in 2020, one out of every five claims were denied, with some insurers denying 80 percent of those claims. About 40 percent of those charges were for COVID-19 services. The state those insured were in also made a significant difference, with the average claim denial rate in Indiana at 29 percent, while only 7 percent in Oregon. Some of the insurers in the state of California that may deny your medical claim include:
Can a Lawyer Really Help Me Get My Denied Health Insurance Claim Approved?
Health insurance denial appeals can be complex and time-consuming. Having a strong Santa Barbara health insurance denial attorney by your side can truly make a difference. When you receive a health insurance claim denial, it is often at a time when you are not feeling your best. You may feel overwhelmed with the appeals process, therefore, could significantly benefit from having health insurance denial attorney Scott Glovsky on your side, handling your appeal. Once a knowledgeable attorney steps in, your insurer is much more likely to render a favorable decision on your behalf.
What is a Bad Faith Insurance Denial?
Insurers often do whatever they can to protect their best interests rather than the best interests of their policyholders. This is known as bad faith, which occurs when your insurer denies a legitimate claim without reason. Insurers are required by law to honor their policies and pay for treatments you need. When they fail to adhere to these laws, bad faith has occurred.
Bad faith could include postponing a payment or appeal, denying a legitimate claim that is covered under your policy, intentionally misrepresenting the language in your insurance contract, or failing to deny your claim within the allotted time. If your insurer failed to provide a written explanation of your claim denial, cited incorrect information on the law, or withheld information directly relevant to your claim, these are also instances of bad faith.
How Santa Barbara Health Insurance Denial Attorney Scott Glovsky Can Help
If your insurer is denying your legitimate medical claim, the impact of that denial could be extensive and could damage your health. It is important that you speak to an experienced Santa Barbara health insurance denial attorney from the Law Offices of Scott Glovsky. Scott has been helping those in situations just like yours for more than two decades. He will fight for the medical treatment you need and go after any insurer who is operating in bad faith. Contact the Law Offices of Scott Glovsky today.