Challenge Insurance Claim Denials if You Don’t Agree with the Dispute
Insurance claims that companies tend to dispute vary. After sustaining an accident-related injury or dealing with a debilitating condition, having to deal with an insurance dispute is frustrating. At Fox Law Office PLLC, we know insurance companies dispute and deny claims to save money, or delay paying settlements.
- Medically Unnecessary
- Out of Network
- Utilizing an Inadequate Health Care Setting
Insurance Providers Dispute & Deny Claims as Medically Unnecessary
The most common dispute made by health insurance companies is deeming the claim as medically unnecessary. Insurance companies determine this by qualifying the claim’s type, frequency, extent, site, duration, and effectiveness as clinically appropriate. Sometimes companies dispute or deny claims that your health care provider said they’d cover after meeting your deductible or copay. In that case, you should definitely challenge the insurance company’s “medically unnecessary” finding.
Why Else Do Companies Dispute & Deny Claims as Medically Unnecessary?
Insurance companies usually dispute and deny claims of testing, imaging, etc. that seems excessive. If you get an MRI for a sprained ankle, your insurance company might dispute that claim as medically unnecessary. Also, companies often dispute treatments, procedures, or medications in claims that aren’t supported by records to which they have access. If they have full access to your records, and still dispute and deny claims, consider seeking legal assistance.
Furthermore, they deny claims for non-medical treatments outside your insurance plan’s network as medically unnecessary and out of network.
Disputes Also Include Out of Network & Inadequate Health Care Setting
Health insurance companies also dispute and often deny claims as “out of network” and an “inadequate health care setting.” Say you have a rare condition that your primary doctors can’t treat. You get a second opinion of an expert physician nearby, but the doctor isn’t in your insurance plan’s network. If you consult that expert, and the doctor bills your insurance company, they’ll likely dispute the claim as out of network. You can request an exception to that finding, or seek legal representation to challenge it.
Why Insurance Providers Dispute and Deny Claims for a Health Care Setting
Maybe having at-home treatment versus hospitalization better meets a patient’s health care needs, but the insurance company disagrees. If anyone files claims for in-home care instead of hospitalization, their companies may dispute and deny claims like that as an inadequate health care setting.
You can challenge such disputes by proving that the health care setting is less expensive, and still meets the patient’s needs. Such proof includes provider recommendations for this health care setting and an approved in-home care treatment plan.
For a free consultation about accidents, personal injury, employment, and insurance related legal services, call Fox Law Office, at (855) 324-3684. Follow us on Facebook for updates. We are happy to discuss other insurance claims that companies tend to dispute.