What to Do When Your Insurance Rejects Your Medical Bills

When your insurance company rejects your medical bills, you have various options. First, relax and understand that the rejection might be due to a minor error and easy to overturn. If the rejection is due to a medical reason, involve the doctor who has performed the procedure. Should all these efforts fail, there are still further avenues open, including a formal appeal, at which stage a lawyer can be of great help.

Investigate

• First, find out what exactly happened. Call your insurer and ask the claims department why your claim was denied. Be courteous and keep in mind that the person you are talking to may not have been involved in the decision to turn down your claim. You will likely to talk to the same person several times, and a friendly tone helps build mutual trust. Once you have an explanation over the phone, request that the same information be sent to you in an email or a letter. This is absolutely crucial, as it leaves the insurer little chance but to accept your claim if you can disprove or remedy the issues raised in the written statement. Without such a statement, however, the insurer can easily raise additional points later.

lnvolve Your Doctor

• While you may be able to correct certain minor mistakes in your insurance claim, most situations require the cooperation of your doctor. Only a trained medical professional can explain why the procedure was medically necessary and thus justified. Filing errors, too, are best handled by professionals at the doctor's office or hospital who correspond with insurance companies regularly and know how to elicit a favorable response. Even if the rejection is due to a late filing or mistake in the paperwork, and not a medical matter, your doctor may be able to use his clout and accelerate the resolution of the matter.

File an Appeal

• If your initial efforts fail, formalize the process and file an appeal. How these appeals are handled varies greatly from state to state. Usually, the appeals process involves an outside medical expert who will mediate, and in some cases arbitrate, between you and the insurer. A lawyer is not a must, but certainly an option. If the rejected claim is large and involves an unusual or a complex medical intervention, a lawyer can greatly improve your chances by bringing in outside medical experts or submitting scientific material to bolster your claims.

Seek a Partial Remedy

• Once an appeal has been filed and a date reserved for a hearing, continue to seek alternatives. Your bargaining position will be stronger at this stage as the insurer will realize that you are ready to put up a good fight, which may eventually force the insurer to pay the entire claim. You may be offered, or you could offer, a partial settlement, whereby some but not all of your claim is honored by the insurer. If your insurance plan is subsidized by your employer, you can also ask your group plan administrator for help. The more people you have on your side, the better your chances for a successful resolution.