What to do When Health Insurance Denies a Payment

When visiting a hospital for a medical consultation like a type of treatment, medical procedure, or test, it may come to mind how much it will cost; however, you do not have to be afraid because that is why Health insurance helps you with your payment.

The benefits are different depending on the Health Insurance you are in. There are different plans you can opt for and it will help you to reduce your medical bills for a short or long time. Although, this does not work every time, as your health insurance can deny the payment of certain medical procedures with your doctors.

This leaves you with unexpected medical bills that you were not prepared for. But this can be resolved in plenty of ways. There are a few reasons why your insurance will not pay, so you should keep reading to learn how to get around these problems and prepare for the next incident.

Health Insurance network providers

Before we get on the reasons why your health insurance will not help you with your payment, you need to understand in-network and out-of-network plans. They are offered by your health care providers and it helps you to save money depending on if your doctor or hospital accepts or not the insurance cost.

Generally, when obtaining health insurance, the company will tell you which are the recommended hospitals and centers with which they have agreements, as well as those that do not.

For example, if during a visit to the doctor you get a bill of $190 and you confirm that the hospital can join your contract and be in-network, you can get financial support from the insurance to make the payment; sometimes they can even pay the total amount.

But, if the doctor or the hospital does not accept the contract, it means that they are out-of-network and you need to pay the bill by yourself. Sometimes, if it is an emergency or if there is a special agreement, the insurance company can pay for a partial amount (for example, $110), and you will have to pay for the remainder (in this case, $80).

So make sure that your hospital is in-network or out-of-network first. This will help you with the payment thanks to your health insurance.

Reasons why your Health Insurance won’t pay

  • Not enough information for support

Sometimes your insurance company wants to know more details about the payment they are about to execute. If you do not give a proper explanation or information is missing in the process, then they will deny your claim.

  • A mistake from the company

Another reason could be because your insurance company is making an error in the process. They could have even paid incorrectly, so they must resolve these problems quickly. You should always document every step taken if you decide to call the company.

  • Your hospital is out-of-network

Do not assume every provider is open to in-network, as dozens of them are not. Your health insurance will not make the payment if they are out-of-network.

  • The insurer does not think the treatment is necessary

Your health plan can also determine whether your health insurance is willing to make the payment or not. If they think that the treatment or medication you got recommended by your doctor is not necessary, your claim can be denied.

This can be solved if your doctor is willing to talk to your insurer so that he can explain the reason why you have to undergo certain procedures.

➡LEARN MORE: Can I Be on My Parents’ Health Insurance and My Own?

Ways to help your claim

  • Review your denial and read the policies of your health insurance

If you think that the insurance company denied your request unfairly, then do not rush. Read carefully the claim denial and your insurance policy. If there is a discrepancy or a mistake, keep a record of the things to show later.

  • Call your insurance company

With all the information you have collected, you could call the health insurance company about the payment denial and see if there was a mistake. This is a better approach as you can talk with your insurer and even clarify things for your next encounters.

  • Seek information with your insurance agent or HR department

Another option is to contact them and ask about your claim denial. You should tell them everything that has happened and provide documentation if needed. They can help you in the process, but also tell you if the insurance company did the right decision to deny it.

  • Appeal the claim

The Affordable Care Act gives you the right to appeal the denial and have your claim reviewed fully by your insurance company, or even another party. An external review does not involve your insurance company.