If your medical claim is denied, that isn’t the end of the process. You can appeal a denial if your treatment was deemed medically necessary, or if there was an error and your insurance company has denied something that they shouldn’t have.
If you checked to make sure your provider and treatment were covered, yet you are still get billed because a provider who is out of your network assisted with your treatment. This is the time to file an appeal. Read below for advice on appealing your denied claim.
Understand Reasons for Denial
There are many different reasons that your insurance company could deny the claim submitted to them. The provider you saw might be out of your insurance network, they may have not given the correct information to your insurance company or a clerical error could have occurred. Sometimes health insurance companies make the determination that the procedure you received from the provider was not medically necessary.
The most common of these reasons is a clerical error. If the billing codes entered at the doctor’s office are incorrect, it can result in a denial from the health insurance plan. If you believe this has happened to you, it is valuable to have a medical billing expert look at your bills to see if it was billed properly. Of course, after you verify that it was billed properly, you still have to make sure that your plan covers the procedure.
Know What is Covered by Your Policy
Health insurance plans are different, and what is covered by one is not covered by another. Even if you think you know how your co-pays work and how much of your treatment should be covered, you should still read through your policy to be sure of what it covers before you write a rebuttal letter. In fact, if you know that you need regular medical treatment, you should have a copy of your health insurance policy easily accessible so that you can review it in cases like this. If you have a policy through your company and you can’t find a copy, your HR department should be able to help you obtain one.
Call your health insurance if you have any questions about your billing, and make notes of the date and time you called and who you spoke to.
Find Out the Reason Your Claim Was Denied
When you receive medical care and billing is submitted to your insurance company, you should receive an explanation of benefits from your insurer. This may be sent to you in the mail or you may receive it electronically, depending on what you have selected to receive from your healthcare provider.
The explanation of benefits will usually say “This is Not a Bill” on the front page, and proceed to break down the cost of the treatment, how much the insurer paid, or why it was denied. A billing expert can look at what treatment was listed and determine if it was submitted correctly.
Gather Your Documentation and Write Your Appeal
The most important piece of documentation from your provider will be something called a “letter of medical necessity” particularly if your claim was denied because your insurer made the determination that your procedure was not necessary to your treatment.
If you need to provide more evidence to your insurer that the treatment was medically necessary, try to find verified studies (peer-reviewed) that are in line with your assertion that the procedure was necessary. Also, if you got a second or third opinion when you were seeking treatment and your providers recommended the same thing, you can use this as evidence.
Make sure your treatment was billed appropriately. For example, a surgery to fix a condition may be denied by your insurance company, but the underlying condition requiring the surgery is covered. You have to make sure that the information was adequately transmitted to your insurance company so they have all the information to review your case. Medical billing is a complicated field, so it may be worth having a billing expert look over your claim to make sure it was handled appropriately.
When you write your letter, it should be straightforward and to the point. Don’t delve into the emotional ramifications of the claims process, provide the facts of the situation and why your treatment should be covered. Include the necessary information for the insurer to know who is being talked about: Name, address, date of birth, insurance identification number, and date the services were provided.
Make sure you start the letter by stating that you are appealing a claim that was denied. In the body of your letter, explain (based on the evidence you collected) why the bill should be paid.
Send your letter by certified mail so you know it was received, then follow up with your insurance company 7 to 10 days later to check on the status of your appeal.
File Your Rebuttal in the Necessary Timeframe
Read your policy to understand the time limits for filing an appeal. Don’t leave it to the last minute because you will need to get documents from your providers, and there will be a time delay for that as well.
If there are many different pieces to your case and you are concerned that the deadline will pass before you can gather everything necessary to make your appeal, write your insurance company a letter and say you are appealing their denial, and are sending more information. Follow up promptly after buying more time.
Why You Need Medical Billing Analysts
It is highly recommended to hire a medical billing expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.
Whether you are a plaintiff or a defendant in a case, one of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.
Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.
The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs. Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.
Contact Medical Billing Analysts by phone or email at 800-292-1919 or firstname.lastname@example.org. We’re here for you, whether you need an evaluation of a single charge or a complex injury case.