Why Are Surgical Procedures Commonly Denied by Insurance?
The good news is that 92.1% of Americans had health insurance at some point in 2022. That is based on information collected by the United States Census Bureau. The bad news is that insurance doesn’t always provide coverage for all procedures. If you or someone in your family are dealing with health issues, you need to know why surgical procedures are commonly denied by insurance.
The following are some of the common reasons why a denial occurs:
The Insurance Policy Does Not Cover the Procedure
Two common types of procedures are Elective and urgent/emergency surgeries. Health insurance policies are very specific about the kinds of procedures they will cover. Your claim will only be allowed if the surgery you need is on that list.
Lapsed Coverage
It will be disheartening to find out you need surgery, but because you missed one premium payment, your coverage has lapsed. On paper, the insurance company has every right to cancel your policy without a grace period. That is why you want to make sure you pay your insurance on time.
Insurance Company Errors
A lot of the surgical approval process is automated. Information is input into the insurance company’s system, and the denial is generated. However, if that original information is wrong, it will be the insurance company’s fault. That might mean reviewing all the claim submissions and verifying they are accurate.
The Cost Exceeds Policy Limits
A 2023 CNN report outlined how health care costs in 2024 were slated to go up by around 8%. Those increases apply to every aspect of health care, including surgical procedures. If the cost of your surgery exceeds the limits of your policy, your carrier will only pay up to the limits. For instance, if your surgery costs $100,000 and your insurance only pays $50,000, you must make up the rest.
Effects of Health Insurance Claim Denials
There was a time when health insurance companies used the pre-existing condition loophole to deny the claim. They found that if you were sick before your insurance started, they should have to pay for procedures to help with that illness. Thanks to the passage of the Affordable Care Act, no insurance company can deny a claim due to pre-existing conditions. However, as mentioned above, claims can be denied for other reasons.
When insurance denies approval for a surgical procedure, it doesn’t mean the surgery shouldn’t happen. Paying those expenses can wipe out a family’s finances, leading to additional stress and anxiety. It might also mean filing for bankruptcy, which is even more reason for stress.
Appealing the Denial
If your health insurer does not approve a surgical procedure, you have options, and that begins with talking to the Law Office of Matthew L. Sharp. We have years of experience dealing with insurance companies and understand their approval process. We can thoroughly review your policy and the procedure to see if there is a way forward towards approval. Keep in mind that this review can happen even after the surgery has already happened.
Call our Reno law office to discuss what is going on with your insurance claim.
