Why Health Insurers Issue Denials?

There are exactly hundreds of reasons a health idea might deny payment for a healthcare service. Some reasons are simple and fairly easy to fix, while some are more tough to address.

Public reasons for health insurance denials include:

Paperwork errors or mix-ups

For example, your healthcare provider’s office acquiesced a claim for John Q. Public, but your insurer has you listed as John O. Public. Or maybe the doctor's office submitted the claim with the incorrect billing code.

Questions about medical necessity

The insurer trusts the requested service is not medically essential. There are two likely reasons for this:1

You really don’t need the requested service.

You need the facility, but you have not persuaded your health insurer of that. Maybe you and your healthcare provider need to offer more information about why your necessity the requested service.

Cost control

The insurer wants you to try a different, usually less expensive, option first. In this case, many times the requested service will be accepted if you try the less luxurious option first and it doesn’t work (step treatment for prescription drugs is a common example of this).2

The service just isn't covered by your plan

The requested service is not an enclosed benefit. This is common for things like cosmetic operation or treatments not accepted by the FDA. It's also shared for services that don't drop within your state's meaning of the Affordable Care Act's essential healthcare benefits—if your idea is obtained in the separate or small group market—which can contain things like acupuncture or chiropractic services. (Note that if you have an employer-sponsored idea that's self-insured or got in the large group marketplace, the ACA's essential healthcare benefits are not required to be enclosed; check your idea details to be sure you appreciate what is and isn't covered by your rule).

Important gaps in covered health benefits are also common if you've bought a plan that isn't regulated by Reasonable Care Act rules (such as a short-term health idea or fixed indemnity plan) and thus doesn't have to protect services that you might otherwise expect a healthcare plan to cover—things like medicine drugs, psychological health care, maternity care, etc.3

Provider network issues

Depending on how your insurance healthcare plan's managed care scheme is structured, you may only have coverage for services provided by healthcare workers and services that are part of your idea's provider network.4 If you go outside the provider network, you can thus imagine your insurer to deny the insurance claim.

If you're looking for prior authorization for a service to be did by an out-of-network provider, the insurer might be eager to consider it if you select a different healthcare provider who is within your idea's network. Alternately, you might try to persuade the insurance company that your chosen earner is the only provider accomplished of providing this service. In that case, they can brand an exception and provide coverage.

Be aware that the provider may equilibrium bill you for the difference between what your insurer wages and what the provider custodies, since this provider hasn't hired a network contract with your insurer.5 The No Surprises Act took inference in January 2022, prohibiting surprise balance billing, which mentions to emergency circumstances or care provided by an out-of-network healthcare provider at an in-network facility. But balance billing is still acceptable if you knowingly pursue care from an out-of-network provider.

Missing details

Maybe there was insufficient information provided with the denied medical claim or pre-authorization request. For example, you’ve demanded an MRI of your foot, but your healthcare provider’s agency didn’t send any info about what was wrong with your foot.

You didn't follow your health plan's rules

Let’s say your healthcare insurance plan requires you to get pre-authorization for a specific non-emergency test. You have the examination done without getting pre-authorization from your guarantor. Your insurer has the right to repudiate payment for that test—even if you actually needed it—because you didn’t shadow the health plan’s rules.6

In any non-emergency condition, your best bet is to exchange your insurer before scheduling a medical claim process, to make sure you follow any instructions they have regarding provider networks, previous authorization, step treatment, etc.

Isabella Bautista is a dedicated healthcare professional. Ms. Isabella Bautista' command over various medical topics gives her an edge as a content writer and sets her apart from the rest.