For example, a denied claim may occur if the provider did not obtain the required prior authorisation for a treatment or if the plan does not cover the service. Talk to an insurance denial lawyer if your claim was wrongfully denied as not medically necessary. You can also try to convince the insurance company that your chosen provider is the only one capable of providing that service. If your insurance plan refuses to approve or pay for a medical claim, including specific tests, procedures or care ordered by your doctor, you have guaranteed rights to appeal.
The Kaiser Family Foundation, a non-profit organisation based in San Francisco, California, meets the need for reliable information on national health issues. Health insurers are working with doctors, hospitals, medical groups and other care providers to improve prior authorisation. ACA transparency data can reveal information about the coverage and operation of health plans that would not otherwise be readily apparent in plan documents. Some insurers attempt to deny liposuction under their general "no cosmetic procedures" rule, even when it is necessary to treat a condition that can leave a person disabled and in chronic pain.
This explanation usually comes in a document called an Explanation of Benefits (EOB) from your insurer. The insurance company must send you an explanation of benefits form that states how much the insurer has paid or why it has denied the claim. Whether your health plan denies a claim for a service you have already received or denies a prior authorisation request, receiving a denial is frustrating. They count on people not having the stamina to challenge every denied claim, even when there is a valid medical reason for a drug or treatment to be covered.
The DOL estimates that about one in seven claims made under the health plans of the companies it oversees is initially denied, or about 200 million claims a year. Handling an appeals process or denied claims increases administrative costs and decreases cash flow, while finding solutions to minimise denial rates can have a positive effect on a provider's bottom line. healthcare Finance News found that one of the most frequent sources of claims denials has nothing to do with medical conditions or policies, but is the result of administrative errors by providers. Providers may have legitimate reasons for denying health insurance claims, but it is also very common for them to fabricate inappropriate reasons for denial.