What should you do if your health care claim has been denied?

Many Americans who rely on insurance companies to cover their treatments and procedures end up missing out on important care.

insurance company Deny 10% to 20% of medical insurance claimsGovernment data is limited, according to a 2023 ProPublica report. On the other hand, one in five adults claim denied Between 2022 and 2023, According to a study by KFF, a nonprofit health information organization.

Many Americans have long-simmering anger toward the health care system, and they took to social media to air their pent-up frustration after UnitedHealthcare CEO Brian Thompson was shot and killed in December. I spat it out. Luigi Mangione, 26, was charged with Thompson’s murder and murder. He faces multiple federal charges.

Health insurance companies will deny coverage if they determine that a treatment or procedure is not medically necessary, requires prior authorization, or if the doctor is not in the insurance company’s network. You can.

“The health insurance market is run by large, publicly traded companies that rely on quarterly profits, because it’s all about money. Care is denied because companies are trying to cut costs. We’ve seen it over and over again,” said Rob Giannelli, a Los Angeles-based insurance attorney.

It can be difficult for patients to fight denied claims on their own. “If it’s a claim that has some consequences, there’s not much you can do to get that result other than hire an attorney,” Giannelli said.

According to Sabrina, under the Affordable Care Act, if you purchase health insurance through the ACA Marketplaces or are enrolled in an employer-sponsored plan, you are entitled to an internal review and that decision will be subject to review. Corlett, a research professor at Georgetown University’s Center on Health Care Reform, said he has the right to an external review if he is not satisfied.

So the steps you can take are: first file Internal appeals to insurance companiesmust be done within 180 days of receiving the rejection notice. Unfortunately, this happens very rarely. HealthCare.gov Consumer Appeal Less than 2/20 of 1% Number of in-network claims denied in 2021, according to KFF. Insurers upheld 59% of the denials that were appealed.

Mona Shah, senior director of policy and strategy at consumer health advocacy group Community Catalyst, said: “Insurance companies often support these denials, but this is because consumers are not aware of their rights or the ability to do so.” “It clearly shows how much he knows his abilities.”

If the insurance company maintains the denial, you can dispute the claim through an external review process. Once the insurance company has made its final decision, there is usually a deadline for filing an external claim.

Your insurance company’s explanation of benefits or the final denial letter you receive from an internal appeal will tell you which organizations are eligible. Process external reviews Where you can contact that group.

“In many cases it may be worth pursuing an appeal. [patients] You will need to work closely with your treatment provider. Providers are often familiar with this process,” says Corlett.

In some states, like alabamain reliance on the federal Department of Health and Human Services, Oversee the external review process.

Other states, like California, have their own programs; independent medical review It depends on the type of insurance you have. This does not apply to people with private group insurance provided by their employer. But those plans typically still have provisions that allow external appeals to be filed outside the state agency, Giannelli said.

California contracts with companies that have doctors in specific specialties. Doctors will review the claims and determine whether the insurance company’s determination of medical necessity was correct, Giannelli said. If it is wrong, the insurance company must reverse the decision.

But Giannelli said medical reviews can sometimes lead to incorrect assessments. If the external review decision upholds the insurance company’s denial, the insured has the right to sue, and that’s where a lawyer like Giannelli comes in.

Other states have also launched their own independent review programs in recent years. like pennsylvania. You can now request a review from . state If your insurance claim is denied. You can apply if you have employer-provided insurance, or if you purchased your insurance through your state’s health insurance marketplace called Penny or directly from your insurance company.

many states too There is a consumer assistance program It helps patients resolve insurance issues by phone, mail, email, or in person. Centers for Medicare and Medicaid Services I have a directory This will allow you to see what resources your state has to offer.

Ruth Lunde, vice president of provider relations at Undue Medical Debt, said even if you haven’t yet received a bill from your provider and are expecting a large bill, your bill could still be canceled or reduced. It says don’t panic.

However, if you are charged an exorbitant amount of money and your medical debts pile up, unjust medical debt has a guide to help you manage your obligations. For example, the guide advises against paying with credit cards or loans, as this can increase your debt. I also suggest telling the hospital or bill collector that you can’t afford the cost. They may be willing to cooperate.

You’re not alone in doing so. “There’s no need to be ashamed of it,” Rand said.