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Medical Claim Denials Revealed

My Emergency My Choice: Medical Claim Denials Revealed

For most people, one of the most stressful and taxing moments of their lives is to find themselves in a medical emergency. Learning that you have just hours, minutes, or seconds to act to ensure you or your child survives is unfortunately a very real reality for many. We have shared many of these stories with you in the past: a patient who flatlined for minutes, a child with leukemia who had to make a decision to trust in their symptoms, a parent fighting for not only their child’s life but for financial accountability from their insurance company. We want to share a few moments from these stories to show what an emergency looks like because often it can be deceiving.

Many patients have one thing in common – once medical treatment has ended and they have recovered, the sense of dread and worry never fully leaves. They are still left with one pivotal question: Will my insurance cover my claim? Medical claim denials are a favored tactic of Insurers used to help pad their profits. Learn more about what they are, how/why they happen, and what you can do as a patient to protect yourself against them.

What Is A Medical Claim Denial?

A medical claim denial is when your health insurance company refuses to pay the request of your health provider (the doctor, hospital or facility you visited) for the services you received during your medical treatment. Simply put, your insurance company is deciding not to pay the bill. 

What Is A Medical Claim Denial?What Is A Medical Claim Denial?

According to The Change Healthcare 2020 Revenue Cycle Denials Index Reportnearly half of all denials are preventable front-end errors or mistakes. These mistakes are easily resolvable issues such as missing data or registration errors when filing the claim. “86% of denials are potentially avoidable [front-end issues and errors]”. Worse yet, of those 86%, 24% of those claims are unrecoverable. This means if you receive a denial, you are often paying for your insurer’s mistake and likely won’t be able to recover any payments you have had to make to your provider while you are appealing the denial.1 

So, why do denials happen?

Read More From Change Healthcare

Why Do Medical Claim Denials Happen?

For every claim that Insurers deny, they increase their profit margin. This is one of the factors that is attributed to the increase in the unrecoverable front end denials mentioned above. To put this in perspective, the total percentage of claims denied due to avoidable care is less than 5% of all denials.1 And, initial submission denials (claims that were systematically denied before review) went from 9% in 2016 to 10% by the first quarter of 2020 and astoundingly raised to a peek of 11% by the third quarter of 2020”.3 

A few other reasons for the increase in front end denials can be attributed to a lack of training that is required to be able to handle these sometimes incredibly complex and dense documents, backlogs of unprocessed claim appeals, and outdated technology or software.2 Clearly, there are ways to help reduce these denials, and many solutions have been presented to health insurers. As of now few to none have been enacted. Many people may be struggling to pay their medical bills simply because their insurer did not properly invest in its employees or technologies.

Why Are Medical Claim Denials Happening More Often?

You might say, “But, I heard that health claim denials have gone down over the last half-decade”. This is simply not true. Denials due to avoidable care or appropriateness of care have decreased 80% since 2016, yet the total number of claim denials actually increased in 2020.1 Denials have increased disproportionately during the second quarter of 2020 in the Pacific Coast (13.1%) and the Northeast (12.9%), the two regions hit hardest by the first wave of the COVID 19 pandemic.2

Watch Pandemic Denials: State Of Denial:

What Should You Do If Your Medical Claim Is Denied?

If you feel like you have a medical claim that has been wrongfully denied and don’t know what to do, please consider reaching out to us by filling out the form on our home page. We will get in contact with you to try and help you stand up and fight back against the unfair practices and tactics these insurers use.

Tell Us Your Story

If you aren’t comfortable or able to contact us, here are some other ways you can work to ensure your insurance company covers your claim.4 

Read your claim denial letter from your insurer.

They are required to give you the exact reason your claim was denied, instructions on how to submit an internal appeal, and outline all deadlines for the internal appeal process. 

Appeal your claim.

Once you receive your letter and learn how to submit an internal appeal, follow the guidelines that they present by the stated deadline. You may be able to submit an extra letter or testimony of your doctor if necessary to help your case.

If your internal appeal doesn’t work, file an external appeal.

Similarly to the step above, if you feel your claim has been unrightfully denied you can ask to bring your appeal to a neutral third party for an external appeal. This is the last chance in order for your claim to be overturned.

For any medical procedure, patients respond to treatment differently, hence each patient's results may vary.
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