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    Claim Denied? 4 Possible Reasons


    There are many reasons insurers deny payment for medical bills. Here are four common ones and steps you can take to get those bills paid.

    1) You didn’t get pre-authorization: Many medical procedures, such as surgeries, require you to get your insurer’s OK before you proceed. Even if the service is generally covered by your policy, if you don’t get prior authorization, your claim is likely to be denied.

    The fix: Check with your plan before you schedule your procedure.

    2) Your care isn’t medically necessary: Insurers will only pay for care that is considered “medically necessary.” That can be a judgment call, and often doctors and insurance companies disagree.

    Insurers review cases both before and after a procedure, and they can come to a different conclusion based on what took place in the operating room. If the procedure you get differs from what your doctor submits a bill for, you may run into a problem.

    The fix: Get a letter of prior authorization from your insurer as well as a letter from your doctor confirming that she plans to perform the exact procedure approved by your health plan. If your claim is denied, or not paid in full, ask that your doctor submit a report showing the details of what was done in the operating room.

    3) Codes don’t match: Each medical procedure has a code that should appear on the pre-authorization letter you receive from your insurer. It’s critical that what is billed by your health care provider matches the procedure your insurer approved. Often, they don’t match, which leads to claims being denied.

    The fix: Check first to see that a simple coding error isn’t the cause of your insurer’s refusal to pay. If it is, have your doctor’s office resubmit the claim with the correct codes.

    4) Your health plan isn’t up on the latest:  Sometimes insurance companies haven’t updated their systems to reflect the latest in clinical research or FDA approval for certain medications or medical devices.

    The fix: Ask for your health care provider’s help in gathering information, or collect medical journal articles that support your treatment. You can search journal articles with PubMed, a service of the U.S. National Library of Medicine, at

    Remember that you have the right by law to at least two levels of appeals with your insurer if your coverage is denied: one internal with your insurer and an external review by an independent third party. Studies have shown that second-level appeals are often ruled in favor of the patient, so it’s worth your time.

    Also, ask any doctors or other health care providers waiting for your payment to place your account on hold while you work things out with your insurer. You don’t want your bills sent to collection agencies while you battle with your health plan.


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