NASHVILLE, Tenn. (WTVF) — You have health insurance to cover your medical bills. But what happens when your insurance denies a claim?
If your health insurance denies a test, a treatment, or a medication your doctor says you need, don’t rush to pay out of pocket. You do have a guaranteed right to appeal that decision— and the good news is, it’s easier to do than you might think.
In 2023, nearly 1 in 5 in-network health insurance claims from plans sold on Healthcare.gov were denied — and it was even worse for out-of-network claims, with more than a third turned down!
But a denial doesn’t mean you should immediately pay out of pocket, or worse, skip the care you need.
Consumer Reports says it's easier to appeal a denial than you might think.
First, call your insurance company. Sometimes, a simple billing mistake or paperwork error is all that’s standing in your way.
“Mistakes can and do happen at multiple points in the claim filing or pre-authorization process, and they are often relatively easy to fix, once you identify them,” said Lisa Gill.
If it was not a mistake, you have the right to appeal.
Ask to speak directly to the reviewer who made the decision and get a clear explanation for why your claim was denied. You’ll need this information for the next step – filing a formal appeal stating that you disagree with the decision.
“You’re going to ask your doctor to help to write a letter that explains the necessity for the procedure and include as many supporting documents as possible – like your medical records and treatment studies and any communication with the insurance company,” said Gill.
Doctors are used to this, so don’t be afraid to ask!
The next step might be the hardest: Waiting. It could take 30 days or longer for an answer. If you need treatment right away, make sure you request an expedited review.
“So, if you get a letter that the insurer is STILL choosing to deny the claim – both Medicare and the private insurance are required by law to give you the reason in writing and tell you how to appeal the decision for review by an independent third party," added Gill.
And if you get your insurance through work, consider asking your human resources department to help. If Medicare denied your claim, consider getting legal help to hear your case before a judge.
There’s a law that’s supposed to protect you from surprise medical bills, but if you still get one, one of the best things you can do is ask for an itemized bill and question every charge before you pay.
Do you have more information about this story? You can email me at jennifer.kraus@newschannel5.com.
Happy Birthday to the YMCA of Middle TN. They just celebrated their 150th anniversary! A lot has changed with the Y over the years. I have personally seen some of that firsthand when I was a long-time board member at the Northwest Family Y and part of their Black Achievers Program. Forrest Sanders has a look back.
- Lelan Statom
