Welcome back! This blog provides financial resources and information for people living with cancer. In this post, I want to focus on dealing with denied insurance claims.
Understanding Denied Insurance Claims: What You Need to Know
When you’re receiving cancer treatment, the last thing you want to worry about is whether your health insurance company will cover your bills. However, sometimes insurance claims are denied. A denied insurance claim means that your health insurance company is refusing to pay for a medical bill that your cancer treatment team submitted after you received care. This situation can be confusing but understanding why claims are denied and how to appeal can help you get the coverage you need.
Why Are Insurance Claims Denied?
Insurance claims can be denied for a variety of reasons. Understanding why this happens can help you figure out what steps to take. Here are some common reasons why insurance companies might deny cancer treatment claims:
- Incorrect Information: Sometimes, simple mistakes cause a denial. For example, incorrect billing codes, misspelled names, or mistyped ID numbers can lead to a denied claim. These errors are easy to fix once identified.
- Uncovered Services: If a service or medication is not covered by your insurance plan, your claim might be denied. For example, some treatments or medications used for cancer may not be covered under your plan’s policy.
- Lack of Prior Authorization: Some treatments require prior approval from your insurance company. If your treatment team didn’t get approval in advance, the claim might be denied.
- Out-of-Network Providers: If the healthcare provider who treated you is not in your insurance network, the claim might be denied. Some plans only cover services from doctors and hospitals that are part of their network.
Be sure to review the Explanation of Benefits (EOB) your insurance company sends. This document will explain why the claim was denied, often with a code or reason listed next to the service provided.
Pro Tip: It’s important not to ignore any mail from your insurance company, even if you’re feeling unwell. Denied claims can be appealed, but only within a certain time frame. To stay organized, try opening mail from your insurance company at least once a week.
How to Appeal a Denied Claim
Appealing a denied claim may seem overwhelming, but it’s often possible to resolve the issue. Here’s how to start:
1. Talk to Your Cancer Treatment Team: Many cancer treatment centers have staff members who handle insurance claims and denials. If they do, they might be able to manage the appeal process for you. Often, claims are denied due to simple clerical errors, and your treatment team can correct the issue quickly.
2. Submit Your Own Appeal: If you prefer to handle the appeal yourself, the process isn’t too difficult. Start by going to your insurance company’s website and looking for instructions on how to appeal denied claims. If a phone call is easier for you, follow these steps:
- Make a List of Questions: Write down any questions you have about the denied claim. Have your insurance policy and the EOB nearby.
- Call the Insurance Company: Use the member services number on your insurance ID card to contact the insurance company. Be prepared for a 30-40 minute call.
- Talk to a Claims Representative: When you speak to a claims representative, ask for their name and direct phone number/extension. Also, ask why your claim was denied and what steps you can take to appeal.
- Stay Calm: It’s easy to get frustrated, especially when dealing with something as important as cancer treatment. However, raising your voice won’t help your case. If you feel overwhelmed, consider having a trusted family member or friend make the call with you.
After your call, you may need to submit a formal appeal letter. Be clear and detailed in explaining why the claim should be paid. For examples of appeal letters, you can check out this resource: Migraine-Sample-Claim-Denial-Letter.pdf (Take out Migraine & enter your cancer diagnosis).
What If It’s More Complicated?
In some cases, the reason for a denied claim is more complicated. For example, insurance companies may decide that the services you received were not medically necessary. This can be difficult when you’re dealing with a cancer diagnosis. In these situations, the insurance company may require additional information from your doctor, such as a detailed explanation of why the treatment was necessary. This is usually done through a “peer-to-peer” appeal.
If internal appeals are unsuccessful, you can request an external review. An external review involves a neutral third party who will review your claim and decide whether the denial was justified. In some cases, this can be very effective. According to the Kaiser Family Foundation, about 45% of external reviews result in successful appeals.
Pro Tip: If you are still facing difficulties with denied claims, you might want to contact a health or insurance claims ombudsman. These professionals are state-appointed advocates who can help you navigate insurance issues. You can find more information by visiting Ombudsman Websites – USOA and selecting your state.
Conclusion
Dealing with denied insurance claims during cancer treatment can be frustrating, but it’s important to stay informed and take action. Understand the reasons why claims are denied, and don’t hesitate to appeal. Whether you’re handling the appeal on your own or with the help of your treatment team, it’s essential to stay organized and follow through on any necessary steps. With persistence, you can often resolve denied claims and ensure that your cancer treatment is covered.
For More Information:
Health Insurance Claim Denied? How to Appeal the Denial (naic.org)
How do I file an appeal? | Medicare
How to appeal an insurance company decision | HealthCare.gov
I hope this information is helpful. If you would like to continue this conversation, please click on the Subscribe button at the top of the Blog page. I would love to hear your comments as well as resources that have worked for you. Please share this information with your family and friends.
Keeping you in my prayers,
Jackie
