How to Appeal a Medical Bill that has been Denied by the Insurance Company
Denied medical claims can be very frustrating for the healthcare consumer. The consumer has no idea where to start the appeal process. A survey by Department of Labor shows anywhere between 15% to 25% of the claims billed to insurance companies are denied for a variety of reasons. The Kaiser Health News has indicated that when you file an appeal to your insurance company, you will have a 50/50 chance for success. The goal of this section is to guide the healthcare consumer through the appeal process with the intent to improve the chances of success.
Healthcare consumer should review every Explanation of Benefit (EOB) statement they receive from their insurance company. Denial reasons/codes will be documented on the EOB statement. This will give the healthcare consumer a starting point. The following is a list of the most common denials the healthcare consumer will experience.
Lack of Precertification
Certain medical services require the healthcare provider to precertify the service. The certification process is not a guarantee of payment by the insurance company but a requirement for potential payment.
Referrals
Referrals are documentation that your primary care doctor has authorized the consumer to be treated by a specialty doctor. Most common in Health Maintenance Organization (HMO) insurance plans.
Medical Necessity/Lack of Information
This is a common denial. Your doctor or medical servicing location did not document or did not justify that the healthcare consumer receiving the medical service was necessary.
Non-Covered Charges
This is the number one reason for denied claims by Aetna, Anthem and Cigna in 2013 according to the AMA’s National Health Insurer Report Card. All non-covered services should be documented in your health insurance policy.
Out of Network Provider
Out of network denials are providers that do not an agreement with your health insurance plan.
Policy Limitations
Many insurance plans have limitations as to the number of services a healthcare can receive, cosmetic procedures or experimental procedures are several examples.
Timely Filing
Healthcare providers can file a health claim late. Most insurance companies have time limits to file a claim. If the healthcare consumer claim was denied for this reason, the consumer should not pay the bill. It is the responsibility of the healthcare provider.
Billing Errors
Healthcare providers make mistakes. Common errors are transposed information, billed the wrong insurance company, incorrect diagnosis, incorrect place of service, lack of a billing modifier or charges on the bill where wrong.
The claim appeals process can be very complex and challenging. The following guides the consumer first, who to call, what questions to ask and what actions to take. Remember, these are not all inclusive steps and serve as a guide. As you start the process, it will become apparent what steps and the detail required you need to start the appeal.
Lack of Precertification
First Call
Ordering Doctor, Medical Service Location
Questions to ask
Ask both; Did you precertify my medical service?
If yes, why did my insurance company deny my claim?
If no, why didn’t you precerify my service?
Actions
If yes, rebill my claim with the pre cert number.
If no, ask them to retro cert the claim and re-bill it. If they can’t, ask them to write off the claim. It was their fault!!
Referrals
First Call
Primary Care Doctor; Specialty Doctor
Questions to ask
Ask both; Did you receive my referral and do you have the number?
If yes, why did my insurance company deny my claim?
If no, why didn’t you process for a referral?
Actions
If yes, rebill my claim with the referral number.
If no, ask them to retro referral the claim and rebill it. If they can’t, ask them to write off the claim. It was their fault!!
Medical Necessity/Lack of Information
First Call
Ordering Doctor; Medical Service Location
Questions to ask
Ask both; Why was my claim denied and what information do you need to send to my insurance company in order for my claim to be paid?
Ask them when will they send the information
Ask them to call you when it is sent.
Tell them you will not pay anything until they complete their tasks
Actions
Follow up with the ordering doctor and medical service location within 30 days to insure they have submitted the information to your insurance company
Follow up with your insurance company to determine if the additional documentation has been received and the claim is processed
If the claim is denied a second time, call the insurance company and find out why. Call the ordering doctor or medical service location with the new information. If they cannot appeal, ask them to write off your bill. They failed !!
Non-Covered Charges
First Call
Insurance Company
Questions to ask
Call the insurance company and ask why my claim was denied and is the medical service excluded under may plan?
Ask the insurance company the specific reason the medical service was non covered?
Actions
This denial reason can be generic when reported to you by your insurance company. You will need to call your insurance to determine the specific reason. Based on the answer form the insurance company will dictate the next steps.
Unfortunately, the appeal process cannot be detailed.
Out of Network Provider
First Call
Insurance Company
Questions to ask
Call the insurance company and ask why my claim was denied and was the provider in network?
Ask the insurance company if the claim was processed correctly under out of net benefits?
Actions
Not many, if any, appeal options with this denial.
Policy Limitations
First Call
Insurance Company
Questions to ask
Call the insurance company and ask why my claim was denied and what are the benefits for the medical services billed?
What are the exact limitations for that specific medical service?
Ask the insurance company if the claim was processed correctly?
Actions
Not many, if any, appeal options with this denial. The only appeal is if the claim was processed incorrectly
Timely Filing
First Call
Doctor or medical service location
Questions to ask
Depending on if the bill was from the doctor or medical service location, call the provider.
Actions
When talking with the healthcare provider ask them to write off the bill. It is their fault!!
Billing Errors
First Call
Doctor, medical service location or insurance company
Questions to ask
Depending on the denial reason code and reason for the denial, call either the doctor, medical service location or insurance company?
Determine the exact reason for the denial. The reason will dictate the next steps?
Once you determine the error type, call the healthcare provider and provide them with the correct information and instruct them to re-bill the claim.
Actions
Follow up if appropriate.
Healthcare Consumer Guidance
The following are several suggestions when appealing denied claims.
- Do not pay the bill until you are satisfied with the outcome of the appeal.
- Find out if your insurance company has deadlines for appealing claims.
- In most instances, the appeal process and the appeal responsibility lies with the healthcare provider. The healthcare consumer coordinates the process and makes sure all parties are delivering.
- Be aggressive. Healthcare providers can be non-responsive when denials and appeals are involved. It is very labor intensive for them.
- Take notes about all discussions with your insurance company and healthcare provider, including dates, names and what was said.
- Keep copies of all correspondence received and sent.
- Some healthcare providers provide advocates to assist consumers. Take advantage if available.
- Be patient, you may appeal 3-4 times before you receive an answer.
Billing claim denials and the appeal process can be very confusing and frustrating. Be patient and follow the guidance provided. Your chances for success will increase.