When it comes to treatment for substance abuse disorders, coverage is often denied because the insurance company deems that the care is not “medically necessary.”
Full Answer
What happens if my health insurance company denies my treatment?
Even if your insurer ultimately denies your treatment, (after you fight the denial) keep in mind that they are not the ultimate authority on your health. Though it may be a major expense, the option to self-pay still remains.
What should I do if my insurance company denied my claim?
If your claim was denied, it is worth making a few calls–to your doctor and your insurance company. It is possible that your claim was simply coded incorrectly. If you clarify the condition, the indication, and the treatment, the insurer may fix the mistake.
What should I do if my insurance denies my surgery?
Continue reading for a discussion of how to handle an insurer’s denial of coverage for surgery, and contact a seasoned and effective Los Angeles insurance denial lawyer if your insurance provider wrongfully denies you coverage for medical care.
Can insurance companies deny surgery for cosmetic reasons?
Insurers may also claim that a procedure is purely “cosmetic.” For example, insurance companies have recently been denying surgical treatments for lipedema because the treatments, such as liposuction, are also used for cosmetic reasons.
Why is a test denied?
It's not uncommon for a test or procedure to be denied simply because it is not coded correctly. Many infuriating denials only require a phone call clarifying the condition and indication. Again, before calling make sure that the treatment you wish to have covered isn't explicitly excluded from your plan.
What to do if your insurance won't pay?
If you are denied care by your payer, there are a few things you can do. Fight the denial. Sometimes all that's required is to get in touch with your payer's customer service.
What do payers know about health care?
What payers know is that among the triangle of health care (you, your doctor, and your payer) everyone's goals are different. You just want to get well. Your insurer wants to make money. Your doctor wants both, though what that means can vary based on the practice.
What are some examples of denials?
Examples in which there may be no alternative include: A rare disease, requiring an expensive drug, surgery, or another form of treatment.
When will health insurance stop covering medical testing?
on February 27, 2020. More and more, health payers are insisting that patients obtain permission before undergoing a medical testing or treatment. And, after review, they may decide not to cover that treatment at all. With the high premiums many people pay, this can be very disconcerting.
Can you be turned down for medical insurance?
There are few frustrations that rival being turned down for coverage after a physician has made a specific recommendation for a therapy to improve your medical condition. This isn't an isolated concern and may occur whether you have private insurance or are covered under a government system such as Medicare or Medicaid. Once you finally feel like you have an answer and/or a solution to a problem , these denials can feel devastating.
Does making the most money mean denying tests?
With payers, making the most money doesn't always mean denying tests. Conditions that aren't properly treated may cost them much more in the long run. While these differences in motivation may be frustrating for patients, it isn't necessarily bad if other equally effective treatments or tests are available.
Why is substance abuse denied by insurance?
When it comes to treatment for substance abuse disorders, coverage is often denied because the insurance company deems that the care is not “medically necessary.”
How can a lawsuit help?
A lawsuit could help patients get back the money they spent out of pocket, including the cost of drug screens and residential care, for addiction treatment. It could also require insurance companies to change the way they process claims.
Can insurance companies put a time limit on MAT?
For instance, the insurance company may be putting an arbitrary time limit on how long the patient can receive MAT – even when the medical community operates under the belief that many opioid patients will need to be treated for life.
What to do if your insurance denies treatment?
For most insurers, you can appeal to two levels within the insurance company and a third time to an independent medical board. If your claim is still denied, you can consider legal action such as an individual civil complaint or a class action lawsuit.
How do insurers justify denials?
Despite such evidence, insurers justify their denials by setting a high threshold in their policies for a treatment not to be considered experimental, and the burden falls on you to prove them wrong. You needn’t give up hope, however.
What to do if your insurance company denies your claim?
If your claim is still denied, you can consider legal action such as an individual civil complaint or a class action lawsuit.
Is there evidence that a treatment is beneficial?
In actuality, there may be abundant evidence showing the treatment is beneficial, including case studies in the medical literature, clinical research, and anecdotal evidence from doctors in the field.
Is health insurance a necessity?
Health insurance is a necessity we can’t afford to be without. When coverage is denied, it’s essential to take action and fight that denial so you can get the care you need when you need it. Insurance companies wrongfully deny coverage at times, but with persistence and the right kind of help, you can get the coverage, ...
How does insurance reduce costs?
Insurers are able to reduce medical costs by pre-negotiating reimbursement rates with hospitals and doctors, who are then listed as part of the insurer’s participating network. Patients usually face significant penalties for receiving treatment from an out-of-network provider or hospital, so even if the treatment is covered by the insurance plan, the patient has to pay more of the charges out of their own pocket. This can be especially problematic if your care requires treatment by multiple ancillary specialists who may not be within the network. Patients rarely learn in advance that the medical facility or specialist their in-network doctor recommends is not in the insurer’s network, thus leading to surprise charges after treatment.
What to do if you believe treatment is experimental?
If you believe the treatment that has been recommended by your doctor may be considered experimental, ask the doctor whether there have been issues obtaining insurance coverage for that treatment; and if so, how those issues have been resolved in the past. Most insurers have also compiled specific written policies or protocols for certain ...
Can cancer be denied?
Certain forms of cancer treatment may also be denied as not medically necessary. Although insurance companies steadfastly maintain that they do not practice medicine, they may question your doctor’s judgment and deem certain medications or therapies, even if FDA-approved, as unnecessary. Not surprisingly, such assessments usually fall heavily on more expensive drugs or treatments such as stem-cell transplants. The treating doctor needs to be able to offer a rationale explaining the medical necessity of prescribed treatment and explain why more invasive or expensive treatment is medically necessary and more effective than less expensive treatment.
What happens if your insurance denies your claim?
If your claim was denied, it is worth making a few calls–to your doctor and your insurance company. It is possible that your claim was simply coded incorrectly.
Why do insurance companies deny liposuction?
Insurers may also claim that a procedure is purely “cosmetic.” For example, insurance companies have recently been denying surgical treatments for lipedema because the treatments, such as liposuction, are also used for cosmetic reasons. Just because something is a cosmetic procedure in one context does not mean that it is not medically necessary in other circumstances; in the case of lipedema, such procedures are necessary to prevent or cure a debilitating condition.
What to do before calling insurance denial lawyer?
Your insurance denial lawyer can help you analyze your policy to establish what procedures are covered.
What to do after a firm denial?
If the initial steps to get coverage fail, you have a few options. You can speak with your doctor and your insurance company about possible alternative treatments. However, unless you want to forego the procedure, your course of action will likely involve challenging the denial.
Can you claim a claim that was coded incorrectly?
It is possible that your claim was simply coded incorrectly. If you clarify the condition, the indication, and the treatment, the insurer may fix the mistake. The insurer might just need some additional evidence before accepting your claim, which you or your doctor can provide.
Does California insurance cover cosmetic surgery?
California law, moreover, requires that insurers cover even procedures that are cosmetic so long as they are necessary to restore a patient’s appearance. For example, insurance providers must cover reconstructive surgery if someone’s face or other body part was severely damaged in an accident.
What to do if your insurance doesn't work?
If that doesn't work, you can file an appeal. "The exact process will depend on your insurer, but it often requires that you work with your doctor to submit an application or letter of appeal," she says. If the appeal is denied, you can file for an independent review through your state's insurance regulator, which can take two months to process, ...
What to do if your insurance doesn't cover your medication?
If your insurer doesn't cover your medication, you have several options to try to get the drug covered or reduce your costs. "Ask a lot of questions," says Brian Colburn, senior vice president of Alegeus, which helps employers with their consumer-directed healthcare solutions.
How many people do CVS Caremark and Express Scripts manage?
Marsh says that the two largest pharmacy benefit managers -- CVS Caremark and Express Scripts -- manage pharmacy benefits for more than 200 million Americans.
What happens if your doctor prescribes a medication?
Your doctor prescribes a medication, but your health coverage declines the prescription and now you have to pay the full price without any help from your health insurance. This growing trend can happen with a new prescription and even a drug you’ve taken for years. This can occur when drug plans change their formularies, ...
Do insurance companies require prior authorization?
Insurers often require prior authorization before approving coverage for more-expensive medications. Prior authorization requires your doctor to fill out a form explaining why you need that medication. The drug may be covered with a letter of medical necessity from your doctor, says Colburn.
Do people with similar conditions get the same coverage?
Many people with a similar condition may have the same trouble getting coverage for their medications. Organizations focusing on the disease often have great resources to help you find assistance.
Why do insurers deny experimental treatment?
Many insurers deny legitimate claims for coverage based on a treatment being “experimental,” but the real reason is because they don’t want to incur high costs of coverage.
What happens when the FDA wrongfully classifies a procedure as experimental in nature?
This means that when the FDA wrongfully classifies a procedure as experimental in nature, patients may suffer from the consequences of lack of coverage. When determining the legality of experimental or investigational treatment denials, a lot comes down to the language of the insurance policy.
Why are experimental treatments considered high risk?
This is primarily why health insurers avoid coverage for such procedures . For any insurance company, predictability is a key part of their operations.
What is the principle behind insurance companies?
The working principle behind insurance companies is supposed to be simple: you pay premiums, and your insurer offers coverage for the cost of treatment when you need it. However, complications arise when insurance companies determine if a treatment is medically necessary or not.
What is the only treatment option for rare medical conditions?
Your only available option may be an experimental or investigational procedure. Rather than continuing to deal with the challenges of your ailment, undergoing a rare/innovative treatment may be your only hope for recovery.
Can an insurer deny treatment based on experimental grounds?
Regardless of these concerns, denying someone treatment based on experimental grounds may result in a lifetime of poor health and even death as a result of one’s condition.
Can insurers cover innovative treatments?
In some cases, an innovative treatment method may not be the best option available for a patient. There may be other more established alternatives available when seekingtreatment. Therefore, insurers may prefer to cover these treatments as opposed to others that are more experimental in nature.
Roots of Insurer Denials of Care
Denials When There Is No Alternative Test Or Treatment
- Denials can be particularly challenging when there is no alternative treatment that is covered. Examples in which there may be no alternative include: 1. A rare disease, requiring an expensive drug, surgery, or another form of treatment. 2. A new form of healthcare technology. 3. Off-label drugs (drugs prescribed for a treatment other than that for...
What Can You Do If You Are Denied Care by A Payer?
- If you are denied coverage for a payer, don't panic. A denial doesn't mean that your payer will absolutely not cover a test or procedure. There are many nuances in medicine and no two people are alike. Sometimes a payer simply needs to be educated as to why a particular test or therapy will be most beneficial for a particular person. Before taking any of the next steps, make a few c…
Bottom Line
- Health insurance denials can be terribly frustrating when you are the patient. Even more so when your healthcare provider believes you should have a particular test or treatment. It's easy to become angry and want to scream. Instead, it's often best to think carefully through your options. As a first step, talk to your healthcare provider about alternatives that are covered. Knowing thes…