Insurance claim denials are common. No matter what the reason is, a simple mistake can land the claim application in jeopardy, and the insurance company might end up denying it. Research from 2016 shows that around 17% of the in-network claims were denied. The denial rate of issuers ranged from less than 1 percent to more than 65 percent. The numbers have only increased in the next years.
Here are some of the common reasons that insurance companies list as a reason for claim denial:
Non-covered Charges
All the insurance policies have their limitations when it comes to the coverage, processes, and treatments that are covered with a specific plan. For example, a general health insurance policy is unlikely to cover any charges for dental surgery or fertility treatments or some other specialized care. Therefore, find what you need, and thoroughly review the policy to see if they are included in it. In case you are sure that a service is included, and still have your claim rejected, seek help from a claim denial lawyer.
Lack of Medical Necessity
This is one of the most common reasons for insurance claim denials. Several health insurance companies state that a treatment/procedure must be medically necessary to treat a condition, injury, or illness. Almost all medical insurance providers deny cosmetic surgery to be medically necessary. Certain conditions require treatments, which are often viewed as a cosmetic procedure. For example, lipedema requires liposuction for treatment. Insurers might deny the claim stating the “no cosmetic procedures” rule, even though the condition can make a person disable or can leave him/her in chronic pain.
Experimental or Investigational Procedures
Insurance companies always require a treatment process to be proven and approved by the medical community and government regulatory bodies before accepting them as the approved treatment/procedure. Treatments that are at the experimental stage and lack the FDA approval or are yet to be accepted by the medical community might not receive insurance coverage. Unfortunately, even though many treatments/procedures have been approved by the FDA and Govt. Regulatory bodies, insurance companies have been denying them or delaying the reimbursements.
Claim Filing Errors
Insurance companies often try to rely on technical errors in the claim form to deny approval. No matter how minor the error is, just a simple typing mistake in the name, address, or other information might delay the entire procedure.
The above things should be kept in mind not only before filing a claim, but also before choosing the right policy.
