Many denials are preventable. They stem from mistakes made throughout the revenue cycle and frequently result in errors that could have been prevented with better coding practices, claim-level edits, medical necessity verifications, and more. However, keep going when a health plan denies a medical procedure or refuses to reimburse you for out-of-network services. Instead, take action by appealing the decision.
Educate Yourself
How to get insurance to cover out of network services? Educating yourself is crucial for anyone facing challenges to insurance denials for out-of-network services. This includes understanding your health plan, which healthcare providers and facilities are in-network and require preauthorization and the typical charges for specific treatments. Your health plan does not cover some healthcare services, while others may be denied based on the insurance company’s definition of medically necessary. In fact, according to a study, insurers deny, on average, 17% of claims. And many of those denials don’t follow basic medical standards or common sense. You can challenge a denial by checking the remark codes on your EOB (Explanation of Benefits). These codes will let you know why the claim was rejected or denied, such as being deemed non-medically necessary or an error in billing. However, fighting a denial requires hours of time, energy, and mental stamina. Only some people have the time or energy to dedicate to this process, especially when faced with a large medical bill or potentially lifesaving treatment. In addition, there is no guarantee that you will win an appeal. Understanding that these processes are not transparent and may be influenced by the insurer’s contracts with healthcare providers or device manufacturers is essential. This means that even a well-researched, evidence-based appeal will only sometimes be successful.
Contact Your Insurance Company
Many health insurance companies have networks of healthcare providers who have negotiated contracts with insurers to provide services at agreed-upon rates. This list of approved providers is called the provider directory. If a doctor or facility is not in the network, the health insurance company will generally only pay a portion of the cost, known as the “allowed amount.” The patient is responsible for the balance. Sometimes, however, a patient has no choice but to use an out-of-network physician or facility. For example, a patient may live in a remote area with limited access to healthcare and must visit an out-of-network specialist for care. In such cases, patients can appeal to cover their out-of-network care. A patient must submit a request for reconsideration to their health insurance company within 60 days of receiving a denial notice. The request should include all claim information, a medical records request, and letters of support from the patient or doctor. Depending on the situation, it may be a good idea to contact your state insurance regulator external-link or consumer assistance program for help submitting a request for reconsideration and an external review of the decision. This can help increase your chances of getting a denied insurance claim reversed.
Review the Denial Letter
If you have received a denial letter, the insurance company or TPA has reviewed your claim and decided that the requested treatment is not covered. This is often the case when you submit a pre-approval request or a bill for out-of-network services. While the first thing you should do when receiving a denial is to read it carefully, it can be challenging to understand the reasoning behind the decision. Many of these letters contain a list of generic descriptions reproduced by the insurance payer and medical jargon that can be challenging to interpret. The key is to look for the code that explains why the claim was denied. This is typically a code like “denial of inpatient admission” or “denial of the DRG.” Using the information you have gathered, finding an appeals process to follow within your insurance plan should be possible. The next step is to assemble the necessary documents and prepare a concise explanation of why the procedure you requested is medically necessary.
Appeal the Decision
Keep going if you receive a denial letter from your insurance company. By law, you have guaranteed rights to appeal the decision, and more than 50 percent of all health insurance appeals for coverage or reimbursement are ultimately successful. When you contact your insurance, request that the representative explain how to submit an appeal and ask if there is an internal process for reversing a claim denial. Request that the representative confirm the deadline to file your appeal and if there is a fee. Write a letter of appeal stating why you believe the denied claim should be reversed. Include a copy of your doctor’s statement of medical necessity and peer-reviewed research articles supporting your appeal claim. The letter should be straightforward.
Schedule an Appointment
Patients often find themselves with hefty medical bills resulting from out-of-network services. When this happens, they must take action to prepare a strong case for coverage so that they don’t have to pay the bill. When preparing an appeal, patients should identify why they went to an out-of-network service provider. They should then gather all the documentation, including peer-reviewed medical studies supporting the treatment or procedure. Next, they should write a concise appeal letter. It is essential to keep emotion out of the letter and clearly state that the medical treatment or service was necessary. Lastly, they should include the doctor’s contact information and ask the provider to hold any billing until an appeal decision is made. Finally, patients should check with their insurance company to see if consumer assistance programs are available to help with the appeal process. This can be particularly helpful when the patient is dealing with a high-deductible or coinsurance plan.
