A couple of years ago I saw a rheumatologist for a problem that developed in my fingers. After obtaining my history and performing a thorough physical examination, the specialist ordered 32 blood tests in an attempt to determine the cause of my problem. A month later I received a bill from the lab for $985. I logged on to my health insurance company’s website and reviewed my Explanation of Benefits (EOB) statement. (An EOB is a document from the insurance company that describes how a medical claim was processed and what the patient owes.) I was surprised to see that several of the tests were denied. A few of the tests were deemed “not medically necessary” by my insurance company. The most expensive of the tests ($494), was deemed “experimental” and was also denied.
As a patient, I was frustrated that a single blood test could cost almost $500 and that I received such a large bill for lab work. As a physician, I was angry that a person without a medical degree determined that tests ordered by my physician were “unnecessary” and “experimental”. I contacted my insurance company and was unable to resolve the issue, so I filed a written appeal.
Before deciding to appeal an insurance denial, it is very important that you review your policy. Your health insurance policy is a contract between you and the insurance company. It delineates what is covered, as well as your rights and responsibilities. Many individuals gloss over this information or don’t bother to read the policy at all, but the details are very important.
There are several reasons an insurance company may deny a claim:
- The service is not covered by your plan.
- The service is deemed “not medically necessary”.
- The service is deemed experimental or investigational.
- The procedure or test requires pre-authorization.
- Many insurance companies require that the physician or hospital obtain approval PRIOR to certain procedures, such as MRI scans or surgical procedures.
- Another insurance company is responsible for the claim.
- If the medical care you received was the result of an automobile accident, an accident at work, or if you have a second health insurance company, another policy may be responsible for payment.
- The care was provided by an out-of-network provider.
- This generally applies to individuals with HMO (Health Maintenance Organization) coverage.
- There is an error with the claim.
- Occasionally, simple clerical errors (like incorrect billing codes or the wrong date of birth) will cause a claim to be denied.
How to file an appeal:
- Be sure you have a clear understanding of the reason for the denial.
The insurance company is obligated to provide the reason(s) for denial. Review your EOB (Explanation of Benefits) statement, available on the company’s website. Next to each denied service there will typically be a numeric code. A legend explaining each code will appear at the end of the document. It is also a good idea to call the insurance company and speak to a representative for a full explanation.
- Review your insurance policy to ensure the reasons for denial are valid.
Focus on covered services and whether there are requirements for pre-authorization.
- Review the insurance company’s process for filing appeals.
Make sure you follow all of the instructions and make note of the deadlines to file.
- Gather the information you will need to state your case.
Jot down notes regarding your illness, doctor visits, medications, and prior tests/procedures/treatment. If previous (approved) therapies have been unsuccessful at treating your condition, this will be important to document. Request a copy of the guidelines the insurance company uses to determine medical necessity.
- Write an appeal letter.
The purpose of your appeal letter is to convince the insurance company to cover the service(s) in question. Provide a brief description of your medical condition, how it impacts your life, and why the proposed medical service is necessary. Provide evidence that your policy covers the service using language from written materials provided by the company or from their website. Consider enlisting the help of your physician to determine if there is medical literature to support the necessity of the service and, if so, be sure to include this information in your letter. (In some cases, the physician will write the appeal letter on your behalf.) Include contact information for you and your physician. Be concise and polite. Send the letter via certified mail.
- Take meticulous notes.
Take notes during every conversation you have with the insurance company. Write down the date of the call, the name of the person with whom you spoke, and a summary of the conversation. Make note of the timeline provided and set a reminder to call for status updates.
- Escalate if necessary.
When discussing your case with the insurance company, always ask to speak to the supervisor if you are not getting the information you need. If you are having difficulty navigating the appeals process on your own, you may be able to get assistance from a third party. Many states offer help with health insurance appeals through Consumer Assistance Programs (CAPs). A quick internet search will provide you with the contact information for your state’s program.
If the insurance company upholds the denial decision after your appeal, you may have the right to request an external review. Consult your insurance company’s policies for more information.
Approximately four weeks after I filed my appeal, my insurance company notified me that they would cover all but one of the laboratory studies. They upheld their decision that the $494 test was experimental so I was responsible for paying those charges. While it was not the outcome I hoped for, I was successful in reducing my out-of-pocket expenses and I felt good about advocating for myself.
Take some time to review your health insurance policy to ensure you know what services are covered. If you feel a medical service is wrongfully denied, consider following these steps to file an appeal. It will be worth your time and effort, especially if the outcome is in your favor.
Are you dealing with an insurance denial? Have you been successful with an appeal? Please leave a comment below. We’d love to hear from you.
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I have been having serious pain in right side under rib for over 2 years. My primary care has done every they could to get Prestige Health to ok my CT Scan (as I’ve had 2 ultrasounds and many blood test, stool test & more and nothing can be found. The pain comes and goes and when it comes it’s so bad my stomach swells and I get sick to my stomach. I called Prestige Health myself and wanted to know why they would deny my CT Scan…I had one person quietly tell me to go to the ER. I never know from one day to the next what is going on with me..I’m 64 on disability and my life has been ruined over this!!! When the pain comes it’s so bad I can’t walk!! I live in Florida!
Wow, Nancy. I’m very sorry to hear this. I encourage you to continue working with your doctor to get to the bottom of your pain. Your doctor is often your best advocate in these situations. I wish you the best of luck.
I have lived with back pain for years.! I have gone thru all the pt and pain clinic and nerve tests before and ultimately had to quit working full time Over the past 3 yrs I’ve gotten worse and can’t even be on my feet for more than an hr and my legs go numb and I get shooting pain they my groin! I had X-rays and act and my primary , Er doc, and my neuro surgeon all tried to get an MRI but my insurance wouldn’t approve it! The first letter we got listed 6 points why and what they wanted me to do before they would
approve it. So I had to jump thru all the hoops agaiin plus here’s
the kicker they wouldn’t approve unless I quit smoking and would have to prove it??? My DRS OFFICE WAS BAFFLED? Also question my CT scan and wanted clarification. Basically
questioning medical professionals?? We did end up doing what was asked and resubmitted again only to get another letter stating they didn’t have proof there was a need for one? Even after CT showed that I had spondylthesis among several other things and that my discs have fragmented and piercing my nerves and / or spinal cord! The second letter basically said thru the pre treatment notification process it appears this procedure would not be an epigram expense under my plan? Per the medical directors review of all documents there is no indication I need an MRI?? And it also says with the absence of severe progressive neurological deficits and mri or any advanced imaging will not receive pre treatment notification?? What does that mean? I talked to my drs office and asked her if she appealed or what the process was and she said she did and told me it was out of their hands and to talk to my company’s hr people? I asked her to
Send me all of the documentation she sent to insurance and she told me she didn’t have it anymore??? I am so confused and frustrated! I guess I just don’t understand how all that works but if 3 drs said I needed one how can they deny it? I would like anyone’s input on this I don’t know what I should do next!
I think this article is about the symptom of a bigger problem.
If you take your car to the mechanic (in most states) they can’t start work without giving you an estimate of the repair. You make your choice with informed consent.
When you went for your lab test. There was no informed consent. There was only your expectation that a professional doctor had determined that these test were medically necessary and your insurance company disagreed and sent you the bill.
If you were a car, this would not be legal.
Great points, Ron!
There is a new trend it appears for lab work for blood to have an out of network Dr look at the results. This adds an amount they determine indiscriminately. It is sent to an out of network doctor so it is not cover. I had to contact the insurance company multiple times on this occasion. My next battle is trying to have insurance pay for blood work not coded wellness. If the blood work is coded wellness I wouldn’t have to pay $300. This is my next battle and I hope I win. It should not matter if the blood work is deemed wellness or diagnoses it’s the same blood work. It’s a game and I hope to win. If you have to have blood work done make sure doctor notes it as wellness not diagnostic.
Issues when an in-network lab is used but the claim is denied as experimental by the insurance. A full price charge of 10x of the In-network price is used and billed to the patient ($500 v $50). It seems unfair that an in-network can change an in-network patient out of network pricing. Appeals were denied.
I’m so sorry this happened, Dave. Something similar happened to me several years ago. Of course, there was no way for you to know that your doctor ordered tests that are considered experimental. Ironically, your doctor likely didn’t know either. Each insurance plan has its own rules and it is impossible to keep up. One of the MANY flaws of our healthcare system.
There should be a way to have the provider change only what is agreed upon if covered. If not it’s undue enrichment by the lab provider..
I have been going to the doctor .with back pain that is going down my
leg and hip.my doctor had SENTrequest.TO my insurance company for a MRi.two time in month.they have denied. I am going to therapy 3 days a week. It not helpings, what do I do.help .please, p.s. I have been in pain for over years.
Hello, I’m sorry to hear you’ve been in pain. Did you follow the advice in the article regarding filing an appeal?
I hate to say it, but I’ve resorted to looking for “coverage bulletins” issued by my insurance company (Cigna). Aetna, UnitedHealthcare and others also have these. These list what procedures and tests will be covered and under what circumstances. If I’m going to have cardiovascular lab work done, for example, I try to find out if there are coverage limitations with certain cardiovascular blood tests. Cigna’s coverage bulletin on the subject indeed lists several tests and their coverage policy(ies) for each. Usually, these fall into one of three categories: (1) Cigna will generally cover the test (no specific limitation, although the test still must be medically necessary); (2) Cigna will cover the test only if certain diagnostic criteria are met (e.g., you must have three risk factors for heart disease); and (3) Cigna will not cover the test under any circumstances. Often the coverage bulletin will say that a certain listed test is deemed experimental or investigational, and thus not medically necessary, and Cigna will not cover it.
This has saved me some angst, but you can’t always check in advance. So this wouldn’t be practical in an urgent or emergency care situation.
It’s ridiculous the lengths to which patients (and doctors) must go to try to limit exposure to large medical bills. But knowledge is power, and at least given the system we have, I strongly recommend reviewing these policy/coverage bulletins if possible. They are (by law, I think) on insurer’s websites and relatively easy to find.
This is great advice, Daryl! Thank you for sharing.