If you recently had an insurance claim denied, then you probably have already experienced the frustration and stress associated with trying to get your insurer to re-evaluate and approve it. Sometimes, insurance agents make mistakes and acknowledge their wrongdoing by correcting the issue and re-submitting the claim for review, however, this doesn’t always work out that way. Receiving a denial notice from your insurance company rather than an Explanation of Benefits (EOB) may have you overwhelmed and uncertain as to how you are going to be able to afford this huge expense that you thought your carrier was going to cover.
So, what are your options? Do you accept the denial letter and attempt to negotiate a payment plan with your physician? Not necessarily.
The fact is, you do have options and the Office of the Insurance Commissioner in Washington State has a solution for you. USAttorneys can also assist you with this matter by helping you find and hire a local Washington insurance claim dispute attorney. One thing to be mindful of is that while you may think of an attorney as someone who represents you in the court of law, the fact is, our insurance lawyers have a significant amount of experience in the field and can share their knowledge with you. They can provide you with advice and guidance on what you should do to attempt to get this claim paid as opposed to sitting back and allowing your insurer to deny something you believe should be covered.
What are Some Common Reasons for a Denied Insurance Claim?
- Your insurer has indicated the procedure, visit, or treatment rendered was not medically necessary. You can submit an appeal letter that proves your medical provider recommended this treatment and it was medically necessary. Sometimes a letter or a copy of the office notes will suffice but that is something you want to discuss with the agent who is handling your claim.
- The visit was considered an experimental treatment. If your insurer has deemed your claim “unpayable” for this reason, you can work to sway their decision by proving one of the following:
- It was medically necessary and identifies as standard treatment by the medical community.
- It is the only treatment that will work for you.
- It is less expensive than the typical treatment you would have for your condition.
- It is a procedure that has been covered by your plan in the past for other patients. You can ask your insurance company about this and they should be able to help you.
- Your office visit was considered out-of-network.
Most insurance companies will only cover visits from physicians that are in-network, which means they accept your insurance and the type of policy you have. In the event, you seek treatment from an out-of-network provider, your insurer will deny your claim. To appeal this decision, you can try to prove that your plan didn’t have access to a provider with the needed specialty in-network.
The best way to appeal the decision of your insurance company is through a letter. The Office of the Insurance Commissioner in Washington State recommends a few ways you can format this and you can view those by clicking here. And don’t forget, USAttorneys is available to help you by providing you with resources that can aid you in hiring the best insurance claims attorney in the state of Washington free of charge.