Perhaps you have recently received a Modesto, CA, health insurance denial for a prescribed treatment your doctor believes will help you get better. If you have been healthy up to this point, you may truly be shocked that your treatment was denied. Unfortunately, health insurance companies are often interested in their balance sheet and keeping stockholders happy so many treatments are denied when they should be covered.
Most people who receive a health insurance denial will not appeal. Perhaps they do not have the time or do not understand the appeal process. Many people simply believe that the insurer will not change its mind, so appealing is a waste of time. This is simply not true. In one year, at least 40 percent of health insurance denial appeals are reversed. Since health insurance companies are not required to divulge how many claims are denied, it is difficult to get a good idea of this number.
Some place it at one in five, while others estimate it could be as high as 30-40 percent. Regardless of the numbers, it can feel like a slap in the face when it happens to you. You have faithfully paid your insurance premiums, and now, when you need your insurer to come through for you, you receive a denial of treatment.
Do not give up! Speak to an aggressive, experienced Modesto health insurance denial attorney from the Law Offices of Scott Glovsky. You will be glad you persisted once you have a strong legal advocate in your corner who stands up for you, your health, and your future.
Why Are Health Insurance Claims Denied?
There are many different reasons a health insurance claim could be denied. It could be missing critical information, is specifically excluded in your policy, the claim could be miscoded, there may not have been sufficient supporting documentation, or you may have inadvertently used an out-of-network provider.
Some of these issues are known as “soft” denials and can be fixed. If you used an out-of-network provider because of an emergency, you can let your insurer know this to see if it makes a difference. More often, health insurance denials are due to the treatment being deemed experimental, investigational, or not medically necessary. If your doctor believes the treatment is medically necessary, this reason can be particularly offensive.
In many cases, these words are code for “too expensive.” Insurers too often don’e want to pay for an expensive treatment, so they may deny it under the guise that it is not medically necessary or is experimental or investigational. While it can be hard to combat these reasons, it is certainly possible, particularly when you have a knowledgeable Modesto health insurance denial attorney by your side.
What Can You Do if You Receive a Modesto, CA, Health Insurance Denial?
Some insurers will ask that you go through step therapy when your doctor prescribes a certain treatment. As an example, your doctor may have prescribed a continuous glucose monitor to help you get your diabetes under control. Because these CGMs are about $200 per month or more, the insurance company may require you to first try Metformin (an older diabetes drug that is relatively inexpensive), then another diabetes drug that is more expensive than Metformin, but less than CGM monitors until your doctor tells the insurer that the first two solutions did not work. Under step therapy, AKA “Fail First,” your insurer may now pay for the CGM prescription. This can be time-consuming and frustrating, but it is often necessary to get your insurer to pay for the treatment you need.
If step therapy is not the answer, you can file an internal appeal, which essentially asks your insurer to look at your claim again and approve it. If the insurer still denies the claim, you can file an external appeal with a neutral third party. Your policy documents should detail the procedure for filing internal and external appeals, but you are much more likely to be taken seriously by your insurer if you have an attorney by your side who is well-versed in fighting big insurance corporations.
Which Insurers are Most Likely to Deny Treatments?
Although any insurer can potentially deny a medical treatment, some are more likely to do so than others. Below are the California health insurers who could deny your medical treatment:
What if Your Health Insurer Is Taking a Long Time to Make a Decision?
Health insurance companies are famous for delaying paying claims. They do this because they hope at least some of these claims will “fall through the cracks” and go unnoticed. This works out well for the insurer because for every claim they do not pay, that much more money goes into the company bank account.
If you keep up with claims that were submitted, you can complain to the insurer when a claim is taking longer than it should. Include with your complaint the pay time frame set by state law, and the date the claim was submitted. Ask your insurer to pay the claim promptly; if you receive a denial, you can appeal.
How the Law Offices of Scott Glovsky Can Help Following a Modesto, CA, Health Insurance Denial
If you have received a Modesto, CA, health insurance denial, call the Law Offices of Scott Glovsky. We do this every day—we help people just like you secure justice after a health insurance denial. We have a long history of successful resolutions and deliberately take fewer cases so we can give each case the attention and care it deserves. Contact the Law Offices of Scott Glovsky today; Modesto health insurance denial attorney Scott Glovsky and his legal team are ready to help you through this difficult time.