How To Appeal a Denied Insurance Claim

We pay for health insurance with the expectation that when the time comes, and we need to pay for an expensive medical procedure or another form of care, that coverage will provide the financial support needed. However, there has been a noted uptick in denied health insurance claims across the country, per the Public Broadcast Service (PBS).

According to a recent study conducted by KFF, nearly 17% of claims made in-network were denied in 2021, with denial rates from different insurers ranging from 2% all the way up to 49%. The study looked at 291.6 million claims made in-network and found that a staggering 48.3 million were denied that year.

Why Could an Insurance Claim be Denied?

Insurance companies have a vested interest in denying fraudulent claims. At their core, these businesses are just that — a business and a business needs to make money to thrive. Fraud prevention is a necessary step to keep all the important profit numbers moving upward. Some of the reasons why a health insurer might deny a claim include:

• Lack of referral or prior authorization
• Use of an out-of-network provider
• Use of an excluded service
• Treatment was deemed not medically necessary

Claims can also be denied due to a clerical error. A mistyped number, incorrect box checked, missing key information, and more can all result in a denied claim. However, an increasing number of denied claims may be tied to new systems insurers are employing to speed up the time it takes to review claims.

Before a claim is rejected, laws governing insurance coverage require that doctors working for insurance companies need to review them first. Adding automation to these systems has been in the works for years now, and it’s now an integral part of how insurance companies manage claims. A 2018 Healthcare Finance News study estimated that automating claims could save insurers $11 billion per year — it’s no surprise that this profit-driven industry would jump at the chance to chase those figures.

However, this automation has added a concerning wrinkle to how — and, in fact, if — claims are being accurately reviewed at all. According to an investigation into Cigna, one of the nation’s largest insurers, its doctors spent an average of 1.2 seconds reviewing each case according to ProPublica. Over the reviewed period, more than 300,000 claims were denied over a two-month span.

One of the key metrics these algorithms look for are mismatches between diagnoses and what the insurer deems to be acceptable tests, treatments, and procedures. Not only does this process rely on an accurate and updated list of what can be considered “acceptable” treatment for every injury, ailment, illness, etc., but it also relies on an automated system being able to accurately read hand-written notes.

There is ongoing coverage of “surprising” medical bills from NPR and KFF Health News called ‘Bill of the Month’ that digs into specific cases in an effort to better understand the health care system. It’s filled with shocking denials of coverage like epinephrine shots and steroids being deemed “not medically necessary” for a life-threatening anaphylactic allergic reaction, claims being rejected because of treatments that were never administered in the first place, newborn children being denied neonatal ICU care, and more.

What Steps Can I Take to Appeal a Denied Health Insurance Claim in Nevada?

Despite this rise in questionably denied claims, only 0.2% of denied claims were appealed to the insurer, according to the same KFF study cited above. It was even rarer for an external appeal to be filed, with barely over 2,500 filed, according to KFF. While there are myriad reasons why someone may not appeal a denied claim, there are tools available that allow for an appeal without necessarily needing to file a lawsuit. If you are looking to appeal your denied claim, you should take the following steps:

• Review the details of why your claim was denied.
• Collect all relevant information, including details of your insurance policy.
• Request information you may be missing from your insurer.
• Contact your healthcare provider’s office to see if they can assist in your appeal.
• Submit the appeal request to your insurer.
• Regularly follow up with your insurer until you receive confirmation.

These steps may seem daunting and may not end in the result you need. With the cost of healthcare rising, securing the coverage you need could mean tens, if not hundreds of thousands of dollars or more that you need to pay for your care. Whether you need assistance fighting a denied claim, delays in payment, underpaid claims, or other hurdles in the way of receiving the compensation you deserve, a knowledgeable health insurance lawyer in Nevada can help you fight for the outcome you need.

If your insurance claim was denied without justification, working with an experienced health insurance attorney can help you fight for the compensation you deserve. The Law Office of Matthew L. Sharp has represented clients in Reno and throughout Nevada in court and at the negotiation table, leveraging his legal expertise to help secure them the insurance coverage they are entitled to receive. Give our offices a call or fill out our online form to give us the details of your case today.