What Are the Next Steps After an Insurance Claim Is Denied?

“Your insurance claim has been denied.” It’s the statement that we all dread. While some people just know it to be part of the process, others panic about how they will pay for everything without help from their insurance. It can rattle the best of us!

You can probably relate if you’ve had an insurance claim denial come through the mail or email. You may wonder if there is anything to do about it, or has everything already been decided? What are your rights? Do you have options? After receiving that daunting insurance claim denial, let’s talk about what to do next.

Why Was Your Insurance Claim Denied in the First Place?

Before you roll over and just pay the patient responsibility portion of your bill, it’s time to dig in and find out all you can about your claim denial. It may require some work, but it’s well worth it a lot of the time!

Let’s face it – insurance claim denials occur because your insurance company is trying to save money by not paying out on your claim. They have many people working for them that are looking for reasons not to pay. They hope that you will just accept the claim denial, pay the remaining amount owed on your own and move on.

When it comes down to it, claims are most commonly denied because of:

• Policy limits – depending on the limits on your policy and how much you have already used of that limit could result in a claim denial. It’s a good idea to track where you are each year and if you are close to hitting any limits laid out by your auto insurance or medical insurance policy. This way, you always know where you stand and can avoid unnecessary or non-urgent expenses.
• Policy coverage – Some things are just not covered under your policy. The more you get to know your insurance plan, the more you can avoid things like “out of network providers” or going to a mechanic that is not covered by your insurance.

Knowing the basics of your insurance coverage, whether it be health insurance, car insurance, or more, can be very beneficial. Keeping these things in mind before and as you plan to use your insurance will help minimize the denials you receive.

What Steps Can Be Taken?

1. Review your notification, explanation of benefits, or other notes and make changes. If there is missing information or something that needs correcting, make the corrections, or ask your doctor’s office to make the necessary changes, and follow all instructions for resubmission. You may need to call your insurance carrier to find out more information about why your claim was denied and how to resubmit it. You may be surprised by what a minor fix it turns out to be!
2. Don’t give up! Insurance claims and all that comes with them are never user-friendly for the general public. Don’t give in. Just a little persistence can go a long way in getting your claim paid out. Educate yourself and do all you can to meet the needed requirements if possible.
3. Don’t wait too long. There are timelines that insurance companies and even states set for claims to be resubmitted or appealed. If you wait too long, your claim will be settled with the information already given to them.
4. Don’t be afraid to submit an appeal. Every insurance company has an appeals process you need to know. It’s been shown that up to 40% of appealed claims are reconsidered at least partially. It sounds like a success story just waiting to happen!
5. Keep precise records and documentation on all claims you dispute. Unfortunately, working through the appeal process or other claim corrections can take weeks and even months. Keeping good notes and documentation will help you remember where your claim is and what your next steps are.

If a legal case is pursued in the future, these records and documentation will be beneficial to your law team and your case!

Exercise Your Right to Appeal

Many people believe that after they have worked with insurance carriers, insurance agents, doctor’s offices, and more, it is the end, and they have done all they can to resolve their claim denial. The truth is, there is always an appeals process that you have the right to use. Remember, it’s not personal. You are simply telling your insurance carrier to “please look into this claim again.”

Fighting big insurance companies can feel daunting and downright exhausting. The paperwork alone will make you cry. Instead, ask your doctor’s office or insurance agent for help understanding the information needed to appeal your claim. They can help clarify any questions you may have and often simplify the process for you.

If an internal does not prove successful, you can then file an external appeal where you have an outside organization look at your claim denial. Usually, an exterior appeal will take place with your state’s insurance regulatory agency. If this reviewer decides that your claim should have been covered, then your insurance company will have to comply with the decision.

Obtain Professional Help

When you’ve done all you can, and it seems your insurance is just pushing your requests aside, it’s time to ask for help from the experienced attorneys at Gainsburgh, Benjamin, David, Meunier & Warshauer. L.L.C. Sometimes claim denials or appeals are either too frustrating or are simply not getting traction with what you are able to do. Our attorney team can move your claim appeal forward faster than you could do on your own.

Let us take the stress and worry off your plate so that you can move on with what’s important to you. You can trust that Gainsburgh, Benjamin, David, Meunier & Warshauer, L.L.C. will advocate for you, helping you get the insurance payout you deserve. Give our team a call today at (504) 522-2304 to discuss your insurance claim in more depth and to schedule a free consultation to see how we can help.