Insurance Denials and Appeals
PAG works daily with patients with a variety of insurance plans who are experiencing the repercussion of an insurance denial for something prescribed to them by their medical team.
Whether you’re working through a simple paperwork submission error, or requesting a formulary exemption to obtain a mediation or accelerated appeal for a medical procedure, it’s important to understand the process and stay organized. This is the key to a successful decision reversal. Our materials help patients have the ability to not only avert situations that commonly result in plan denials, but help them form an approach that will increase their chances for binding reversals of a negative decision by their plan.
If your insurance company informs you that it deems a service, medicine or treatment not to be part of your benefits, that means it has refused to pay the cost of that item or procedure. Denials can be distressing for patients and their providers, often causing financial and emotional distress. Taking time to deal with the denial can add significantly to the frustration of the situation and cause further delay especially if the denial is related to care that your doctor or provider concludes is vital to your well being.
It’s important to understand that there may be instances where your insurance is not contributing towards the cost of your care, but it’s not because they have refused to pay for your services. Sometimes there are small things that can be rectified by resubmitting the claim, once you find the error. For example, maybe your doctor has not forwarded the claim to your insurer and is therefore requiring you to pay 100% of the bill or your pharmacy doesn’t have up to date insurance info and is unable to run the cost of the medication through your insurance. Sometimes, there is a mistake in the submission where typos created a discrepancy of codes or documentation, or something is missing from the submission causing processing errors and subsequently holding up the process. There are also times where what you are petitioning for is out of the range of benefits allowed to you and is listed as a service or item which is not included in your plan.
Nevertheless, once you have collected information about the situation and verified that the insurer has reviewed your benefits yet still denies your claim, there is a process for requesting for a re-evaluation. This is called an ‘appeal’ and every plan is now required to give the opportunity to its plan members to submit a request, and the plan must be up front about the process and deadlines involved in the appeal process . PAG’s materials will help you understand the reasons why your care or medication may have been denied, and how to put together an appeal packet that could help.
An analogy of the process and the factors that come into play might be if you just bought a new car but then had an issue that you thought was covered under the car’s warranty. If you bring your car to a garage that is not authorized to service your car under your warranty, then your warranty won’t cover the service on your car as your warranty is only valid if you take it to a dealer or approved location by the manufacturer. And if, for example, you get a scratch or dent on your new car and bring it into the dealer, they probably won’t cover the repairs because normal wear and tear is not covered under your warranty.