If your health insurance denies a test, treatment or medication your doctor says you need, don’t rush to pay out of pocket.
In 2023, nearly 1 in 5 in-network claims from plans sold on Healthcare.gov were denied. For out-of-network claims, more than one-third were turned down.
However, a denial doesn’t mean you should skip the care or cover the cost yourself.
According to Consumer Reports, you have a guaranteed right to appeal that decision, and the process may be easier than you think.
Start by calling your insurance company. A simple billing mistake or paperwork error might be the only thing standing in your way.
“Mistakes can and do happen at multiple points in the claim-filing or pre-authorization process, and they are often relatively easy to fix, once you identify them,” said Lisa Gill of Consumer Reports.
If it’s not a mistake, you still have options.
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Ask to speak directly with the reviewer who made the decision and get a clear explanation for why your claim was denied. You’ll need that information to file a formal appeal.
“You’re going to ask your doctor to help to write a letter that explains the necessity for the procedure and include as many supporting document as possible, like your medical records and treatment studies and any communication with the insurance company,” Gill said.
Doctors are familiar with the process, so don’t hesitate to ask for their help.
After filing an appeal, you may need to wait 30 days or more for an answer. If the treatment is urgent, request an expedited review.
“So, if you get a letter that the insurer is still choosing to deny the claim, both Medicare and the private insurance are required by law to give you the reason in writing and tell you how to appeal the decision for review by an independent third party,” said Gill.
If you get insurance through work, consider asking your human resources department for assistance.
If Medicare denied your claim, seek legal help to present your case before a judge.
A recent federal law, the No Surprises Act, is designed to protect you from unexpected medical bills. If you still receive one, Consumer Reports recommends requesting an itemized bill and questioning every charge before paying.
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