What to do if Your Insurance Denied a Claim

You had it scheduled.

You lined up time off.

You prepared yourself mentally.

Maybe you even felt relief knowing there was finally a plan in place.

Then the call comes: “Insurance denied the procedure.”

That hurts.

It feels like someone just pulled the rug out from under you. You start wondering if something serious is wrong… or if you’re going to be stuck fighting the system.

Take a breath.

A denial does not mean you are out of options. It usually means something in the process needs to be corrected or clarified.

**There is almost always a path forward.**

Why Procedures Get Denied

Most denials aren’t dramatic medical decisions. They are administrative. Healthcare runs on documentation and communication between your medical provider and the insurance company.

When the doctor notifies your insurance about a procedure it could have missing paperwork, the wrong diagnosis code could have been used, providers may not have clearly explained their thinking, prior medical history may not have been provided, the list of possibilities goes on and on.

There are lots of opportunities for errors to happen. In fact, a simple typo could be all that is needed to derail a scheduled procedure. Denials are frustrating, but oftentimes fixable.

Three Types of Denials You May Encounter

1) Pre-Authorizations

Many procedures require approval by the insurance company before they’re performed. The doctor’s office submits records and requests authorization. The insurance company reviews it and either approves or denies it. If it’s denied, it usually means something was missing, unclear, or didn’t meet necessary medical criteria.

Pre-authorizations are common and are typically approved with little to no effort by you, the patient.

2) Step Therapy Requirement

Sometimes insurance requires you to try a more conservative treatment before trying a treatment path that is more invasive or expensive for the patient.

For example:

• Physical therapy before surgery

• Medication before a procedure

• Medicine A before medicine B.

  
  

If those steps weren’t completed, or if they weren't documented properly, the procedure may be denied.

3) Straight Denial

In some cases, a procedure may not be medically necessary, may not be proven to be successful, or may not be covered by your insurance. If you experience one of these three it does not automatically mean your doctor is wrong. It also does not mean that you won't be able to get your procedure. It simply means more work may be needed in order to get your procedure approved.

What To Do If Your Procedure Gets Denied

Step 1: Call the Insurance company

• Ask why your request was denied. Get the exact reason, write it down, and ask what needs to happen in order for your request to be approved.

  
  

Step 2: Call the medical provider's office

• Ask them why your request was denied as well as the other questions you asked the insurance company.

• The insurance company and the medical provider's office often give different answers. That difference is usually where the problem is hiding. If there is a difference, make sure you bring it to the medical provider's attention.

  
  

Step 3: Make Sure Your Medical Provider and His / Her Team Knows

• Do not assume the physician is aware of the details.  Authorization teams, billing teams, and clinical teams are often separate. If you don’t bring it up, it may not get noticed. Ask your doctor what their plan is to get your request approved.

Step 4: Ask About an Appeal

• If your doctor believes the procedure is medically necessary, ask them to submit an appeal. Appeals are common. Many are successful when additional records, imaging, or clearer documentation are provided.

  
  

Step 5: Stay On Top of It

• People get busy, offices get distracted, and files sit in queues. Doctors are overworked, distracted, and sometimes even a bit lazy.

Follow up with them to confirm paperwork was sent, confirm it was received, and ask for updates. The more you call, the more you stay top of mind. Persistence moves things forward.

Recap

If a scheduled procedure gets denied:

1) Don’t panic.

2) Know that Most denials are administrative.

3) Get answers from both the insurance company and the provider to find out why it was denied.

4) Make sure your doctor is involved and aware of the issue.

5) Ask about an appeal.

6) Stay persistent.