It can be deeply frustrating to have your insurance provider deny your claim for treatment or a medical procedure. Unfortunately, this scenario is fairly common: the American Medical Association estimates that 1.82 percent of commercial insurance claims were denied in the year 2013. Considering that there are approximately 1.5 billion claims filed each year, then the number of denials is in the tens of millions. Stop Insurance Denial Law Firm has the know-how and experience to provide you with expert legal advice to help you best make your case. We serve clients all over the United States and we have a long track record of dealing with insurance providers.

Why Was Your Claim Denied?

The first step is always to identify why the insurance company has denied your claim. You may contact the insurer directly as well as confer with your doctor or the hospital to determine why you were denied. The company’s reasoning behind the denial will provide you with some insight as to what your options are moving forward. Whatever the reason may be, it is always wise to proceed with professional legal counsel. Doing so will ensure that you have someone experienced and knowledgeable in health claim denials.

There are various reasons that the healthcare provider may have issued a denial. The insurance provider may deny your claim because the medical services or procedures are not covered by your policy. In other words, the benefit is not offered by your particular health plan. This is a common reason and is especially prevalent amongst customers who have opted for less expensive and more cost-conscious plans. These policies are frequently very limited in the services they offer.

If a procedure is considered to be “experimental”, “cosmetic” (also known as an “elective” procedure), or “investigational”, then the company will likely deny your claim. Experimental means that the procedure has not been widely approved yet and is still in the early stages of development. Cosmetic means that it is not a necessary procedure but is done for personal reasons (though, in some cases, insurance companies must still cover these operations). Investigational means that the procedure is not a treatment but rather a diagnostic tool; in other words, the procedure is being used to determine what is wrong with the patient.

A reason that is related to these but is still somewhat distinct is if the provider deems the treatment or procedure as “not medically necessary”. This is a complex scenario, as this is a frequent reason that some unscrupulous providers will give in order to justify illegitimately denying medical claims. If your clinician or the practitioners treating you deem the procedure as necessary, then you stand a decent chance of eventually getting it approved, even if it’s on final appeal. 

The provider may also issue a denial because a referral or pre-authorization was required. This just means that you were required to seek pre-approval for the service or that you needed to have your primary care physician (also known as a PCP) provide a referral to a specialist. You may also be denied because you visited a provider who was out-of-network; this means that they are not on your health plan.

There are also various clerical or administrative reasons for being denied. These include a denial for timeliness, typographical errors (the request was not filled out properly), or due to policy limitations. These are all fairly easily addressed and just need to be dealt with during the appeals process. In some of these cases, the physician themselves has to make the necessary corrections. The provider may also claim that you are not on the plan at all because you gave incomplete or false information when you applied for the coverage in the first place.

One of the trickiest and most challenging reasons for a denial is if the provider claims that you are suffering from a “pre-existing condition”. This means that whatever medical condition you have predates your coverage with the provider. This can be an incredibly frustrating scenario, and next to the “not medically necessary” argument, is undoubtedly the most common reason that unscrupulous providers will give in order to justify denying a claim. Thankfully, the federal law known as the Affordable Care Act (also referred to as the ACA) has imposed some restrictions on providers’ ability to use this reasoning.

What Is the Internal Appeals Process?

Now that you have identified the provider’s reason for denying your claim, you can move forward the appeals process. Generally, the next step in this protocol is to engage with the provider’s internal appeals apparatus; this was usually set up precisely to deal with these types of situations. You are allowed to file an internal appeal if your insurance plan will not provide or pay for the cost medical treatment that you believe should be covered under your plan.

There are three fundamental steps for the process of internal appeals:

  1. You must file the initial claim. This claim is basically an official request for some kind of medical coverage. Either you or your health care practitioner will generally file a claim seeking reimbursement for the costs of medical treatment and/or clinical services.
  2. Your provider denies this claim. The company must notify you of the denial  in written form and give a reason why within fifteen days if you are seeking prior authorization for a procedure, within thirty days for medical treatment you have already received (like a visit to the Emergency Room, for example), and within seventy-two hours for cases that require urgent or immediate treatment. See the previous section for a detailed discussion of all the reasons why your provider may deny your claim.
  3. You may then file an internal appeal within your provider’s company. You must complete all the forms that are required of your provider. You will also have to provide your full name, contact information, the number of your insurance claim, and health policy identification number. If you have additional documentation, such as a letter from your clinician or the facility where you received treatment, then, by all means, you must include it. It is imperative that you include as much hard, physical evidence as possible. This will only make your case stronger.

At this point in time, you are still proceeding forward with the assumption that all parties involved, including your insurance provider, are acting in good faith. That means that no one has malicious intent to unlawfully deprive you of services that you are entitled to (such as insurance). If you eventually determine that your provider is acting in bad faith or with malice, then there is a protocol to follow for that eventuality.

If you feel overwhelmed or do not feel particularly confident in your language skills, then The Consumer Assistance Program can file your appeal on your behalf. The regional office for California is located in San Diego at 7850 Mission Center Court, Suite 104. The number to that office is (619) 922-7501.

Internal Appeals Time Limits

There is a time limit, however: you are required to file your internal appeal within one-hundred and eighty days or six months of having received the notice denying your claim. The appeal must also be completed within thirty (30) days if it is for a service you are yet to receive. If you have already received the treatment or service, then you have sixty (60) days to complete the appeal.

If you are faced with an urgent medical situation that is time-sensitive, then you may request an external review to run concurrently with your internal appeal. Furthermore, a final decision regarding your appeal must come as quickly as possible if your medical condition requires urgency, and at least within four (4) business days after your request has been received. Your provider may provide this final, expedited decision verbally, though it must be followed by a written notice within forty-eight (48) hours.

If you go through this internal appeal process and your provider still denies your claim, then you may file for an external review.

What Kind of Documentation Do I Need?

It is imperative that you always keep copies of any documentation and information as it relates to the claim and its denial. This is especially true if you will eventually need to make a case that your provider is acting in bad faith or is criminally negligent.

This documentation includes all the information your provider sends to you as well as all the information you send to your provider. Essentially, be sure to save all papers that you receive and make copies of any papers you send them.

The most important bits of documentation include the “Explanation of Benefits” letters or forms that explicitly show you what payments and/or procedures were denied. You should also keep a copy of the internal appeal request that was sent by you to your provider.

It is also important to retain any and all documents that have additional information that you forwarded to the provider. This may include a letter from your primary care physician, documentation from the hospital (including imaging records, discharge papers, any and all diagnosis notes, and so on). It is vital that you save everything in order to make your case as strong as possible.

Throughout the course of your treatment, you will likely sign countless papers or forms – save all of these. These signed documents may have crucial information that will help your case. This also includes instances where you ask your physician or some designated representative to file the appeal on your behalf.

You should also be tracking any and all communications you have with your insurance provider. This includes dates and notes from all phone conversations regarding your case and appeal that you had with your physician or with your insurance company. Always remember to include the date, name. time, and professional title of the person you spoke to as well as all details from the conversation. Be thorough in your documentation, as you never know what may come in handy further on down the road.

All this may seem tedious and overly cautious, but the more documentation and evidence you can provide to your legal team, then the stronger your case will be. This is all assuming that your provider acted in good faith and made an honest mistake; if they are operating in bad faith and have malicious intent, then it is even more important that you meticulously catalog all communications, correspondence, and contact.

What Is External Review?

Once you finish the process of internal appeals, then your provider is required to give you a decision in writing. If your claim has still been denied by your provider, then you may request what is known as “external review”. Your provider is legally required, in their final determination and response to your internal appeal, to provide you with the information on how to ask for an external review.

Then you file an external review using the information provided by your insurance company. You are obligated to file a request in writing for an external review that is within sixty days of the day your provider issued you its final decision. Certain health plans allow you to have more than sixty days to make this request. The written notice you receive from your insurance company must provide you with the timeframe required for you to make your external review request.

Once you have filed your claim, all you have to do is wait for the external reviewer to issue their final and binding decision. This external review will either uphold your provider’s decision or it will rule in your favor. Fortunately, your provider is legally required to accept the ruling of the external reviewer.

The kinds of coverage denials that are potentially up for external review include:

  1. A coverage denial involving a judgment for medical treatment where you or your insurance company may disagree about the specifics of your coverage plan.
  2. A coverage denial that determined a treatment was “investigational” or “experimental”.
  3. The cancellation of insurance based on the fact that you gave incomplete and/or false information when first applying for insurance.

Insurance providers in all 50 states are legally required to take part in the process of external review so that it meets or exceeds the standards of consumer protection of the relevant law. Furthermore, your state likely has a process for external review that exceeds these minimum standards. This is the case in the state of California. As a result, insurance providers in California will follow the state’s process of external review. As you go through the process, you will receive all the provisions afforded to you outlined by your insurance provider (in accordance with state law).

If your particular state lacks a process of external review that meets or exceeds the standards of  consumer protection, then the federal agency known as the Department of Health and Human Services (also called the HHS) can handle the act of overseeing the process of external review for insurance providers operating in your particular state.

Depending on the specifics of your coverage policy and which state you live in, then your insurance company may elect to take part in a process overseen by the HSS. They may also choose to contract with any number of organizations that oversee the independent review. However, if you have coverage provided by your employer, then you may be ineligible take part in the process of external review that is run by your particular state. If your provider does not take part in a process of external review that is overseen by the state or HHS, then they are obligated to work with an independent organization.

If you wish to learn more about your state’s external review process, then you should look over the information provided to you on the Explanation of Benefits (also known as the EOB) as well as in the final denial notice from your internal appeals process. You should be able to find all the contact information for your process of external review.

All standard external reviews are decided promptly; no longer than sixty days after the date of the review request being received.

Lawsuits and Bad Faith Claim Denials

It is important to remember that all insurance is a kind of contract between the provider and customer. If both internal appeals and external review fail, and you or your legal team believe that your provider is acting in bad faith or with malicious intent, then you have the option to file a lawsuit.

Keep in mind that most lawsuits for denials are predicated on a breach of contract claim. The area of law that deals with contracts comprehensively allows for a variety of obligations and duties between contracting parties.

One of these is the duty to deal in good faith. If your provider is guilty of fabricating evidence, refusing to accept evidence, refusing to conduct an investigation, causing unreasonable delays in the investigation, requiring unreasonable adherence to minor administrative, procedural, and/or bureaucratic requirements, or exhibiting any evidence of fundamentally unfair behavior, then you likely have grounds for a bad faith/breach of contract lawsuit.

In these cases, it is absolutely necessary to work with a legal team who can guide you through the litigation process.

Find An Insurance Denial Attorney Near Me?

As a patient and customer of the insurance company, it is important to know your rights when appealing the denial of your claims. Whether you are pursuing an internal appeal, an external review, or filing a bad faith lawsuit, then you should have Stop Insurance Denial Law Firm in your corner. We will fight for you and give you the best chance of winning. Call our insurance denial lawyer at 310-878-1771 and get started as soon as possible!