When the Insurance Company Denies Your Claim

The recent tragic killing of the United Healthcare CEO ignited renewed frustration with health insurance companies and their denial of medical claims. According to a 2023 KFF survey, about 1 in 5 respondents in employer-sponsored or ACA marketplace plans experienced a claim denial that year. And in a 2023 Commonwealth Fund survey, 80% of respondents said the denial created worry and anxiety, while 47% of respondents said the health problem worsened.¹

So, what can you do if the insurance company denies your claim to cover medical expenses?

First, you can appeal the denial. Based on another recent survey, more than half of the claims denied (54%) were eventually overturned and paid.² Yes, an appeal of a denied claim takes time and effort, but the financial and health implications may be worth it.
Your appeal rights should be outlined along with instructions. Make sure you read the details and note the timeframe within which an appeal should be submitted. In some instances, you can request an expedited appeal to which the insurance company must respond more quickly. And depending on the type of claim and reason for the denial, you may also have the right to request an external review by an independent review organization (IRO).
Find out why the claim was denied. Was there a missing or erroneous medical code on the claim? Did your provider not submit information requested or needed based on the terms of coverage? Did the medical procedure require pre-authorization that was not obtained? Was the service deemed medically unnecessary? Was the plan’s deductible not met? Was the claim filed too late?
When you receive the denial letter, check to see if there is mention of a same or similar specialty review. Depending on which stage of appeal you are in the process, a physician in the applicable specialty should also be involved in the review process, e.g., review of a denial of back surgery by an orthopedic surgeon.
If you call the insurance company, it’s likely the first person you speak with does not have the ability to change the denial. They may need to route the request to the appropriate area, e.g., denial is based on non-coverage of the requested service vs. denial based on medical necessity. You may also need to escalate the matter and ask to speak to a supervisor or manager.
Ask your healthcare practitioner for help with the appeal. For example, if the service met medically necessity criteria or there wasn’t time for pre-authorization, the healthcare practitioner can provide an explanation. If there was a coding error, this can be corrected.
In the case of a hospital or healthcare facility charge, you may need a more detailed bill, itemizing each individual charge. Sometimes errors can occur, or charges can be out-of-line, and the billing office should be notified to correct the costs.
In addition, there may be a patient relations representative/advocate who can help you navigate the issue. Sometimes you can negotiate the charges with the clinician or healthcare facility, or a payment plan may be possible.
In some larger companies, your employer’s health plan is self-insured, meaning that your company pays the costs of the medical claims and uses an insurance company to administer the claims. You may be able to appeal further by contacting your company’s benefits department after you’ve exhausted all appeals with the insurance company.
There may be third-party resources through your state or local health authority who can help guide you through the appeal process or negotiate on your behalf. Depending on the size of the charge, it may be worthwhile exploring companies that can advocate on your behalf.

The key is to persevere. If you believe your claim was unfairly denied, keep pursuing the appeal.

And if you are interested in learning more about how to navigate the U.S. healthcare system, check out my book, coauthored with Z. Colette Edwards, MD, Navigating Your Healthcare Journey: Lessons Learned to Get the Care You Need and Deserve, available from Amazon, Barnes & Noble, and bookshop.org (https://www.navigatingyourhealthcarejourney.com).

¹https://www.usnews.com/news/health-news/articles/2024-12-11/how-often-do-health-insurers-deny-patient-claims

²https://www.beckershospitalreview.com/finance/percentage-of-initial-denials-overturned-by-payer-type.html