Health Insurance Claim Denials

Health Insurance Claim

There are many different health insurance policies available for potential policyholders to purchase today. With the variety of insurance policies come a variety of tactics on behalf of your insurance provider to deny your claims.

In the past, one of the most common forms of denial when it came to health insurance claims is the argument of a pre-existing condition. However, now the Patient Protection and Affordable Care Act are eliminating the possibility of a pre-existing condition denial. If you are still receiving a claim denial from your insurance company on the basis that you have a pre-existing medical condition, please contact the attorneys at the Merlin Law Group for help.

Many issues have also reportedly arisen during the pre-approval process for health insurance. Whether there is miscommunication, misinterpretation or misrepresentation during the pre-approval process, the insurance company will often place blame on the policyholder. All too often, health insurance companies will deny a claim stating that your proposed medical procedure is in fact not necessary or in their professional opinion, “too experimental”. In these instances, perhaps further industry professional opinions are necessary. The attorneys at Merlin Law Group can assist with that.

Oftentimes, a health insurance claim denial can come simply from a clerical mistake. When it comes to the health insurance arena, there are many different areas in which your insurance provider can find a possible cause for denial.

Understanding Benefits

Do you ever have difficulty determining how a certain amount has been deemed as patient responsibility? Have you ever had trouble figuring what is applied to your annual out of pocket max? Have you ever asked yourself what is a deductible? What is a co-pay? What is the difference between in and out of network? There are many policyholders who do not fully understand their policies and Merlin Law Group can certainly help with that.

There are many factors that determine whether or not your health insurance claim is being appropriately processed. The Merlin Law Group is there for you when you run into these questions. The attorneys at Merlin Law Group are highly experienced in reviewing insurance policies, understanding insurance policies, understanding the explanation of benefits in relation to the medical services and the insurance policy and more

Healthy Insurance Denied

Surgery is typically very expensive and a topic of great importance. Whether or not your health insurance contract requires pre-approval, sometimes called pre-certification for a surgery, it is strongly advised. Most health insurance policies will state in fine print that a pre-approval does not constitute a coverage decision. While it doesn’t necessarily lead to a coverage decision, it is an asset for the policyholder if their insurance company were to deny a claim pertaining to a surgery received.

Due to the expense, surgery claims are often denied by insurance companies. Health insurance companies can be more concerned with profit and the bottom line than the patients. Surgery claims are often denied on medical necessity grounds. The insurance company will often have an in house physician who did not meet you before, during, or after the surgery and they will state that there was another option. Merlin Law Group can help you overcome these obstacles.

Medications and prescriptions can cost thousands of dollars and this causes them to be frequently denied. Health insurance companies may try to force a generic prescription upon their policyholder even though the policyholder’s medical provider or pharmacy is advising a name brand.

A medical provider could prescribe a combination of medications and the insurance company comes back and says its in-house physician, who has never met you but reviewed your file, deems that combination of medications as not necessary.

Another trend is health insurance companies outsourcing the medication aspect of their coverage to other companies.

The complexity in the medical prescription arena is certainly increasing and there are many claim denials and underpayments.

Many times, patients obtain pre-approval of their surgeries from their insurance companies and their claims are still denied. Medical providers of these patients and policyholders obtain pre-approval from the insurance company of the procedure before it occurred and now the insurance company is denying coverage.

Pre-approvals and pre-certifications are helpful, but do not typically determine and coverage decision. It is very common for insurance policies to state in fine print that pre-approval does not mean there will ultimately be coverage. There is a different coverage department who will review the procedures after they have occurred.

Pre-approval/pre-certification in writing is still heavily advised as it is very helpful for your attorney if you were to choose that route in obtaining coverage.

Waiting period provisions are included in many health insurance policies; however, many policyholders do not fully understand them. Insurance companies angle these waiting period provisions against the policyholder to deny coverage.

It is important to be aware of these waiting period provisions as they vary from three months to six months and say that certain procedures specified in the policy cannot be treated within this waiting period and receive coverage in the end.

There can be exceptions to this waiting period exclusion and emergencies can be one of them. There are more ways to work around the waiting period provision but it is very important to be mindful of them as a policyholder. Pre-approval is still valuable in this scenario.

If the procedure can be scheduled around this waiting period and don’t jeopardize your health, then it is important to work around it. However, in the case of an emergency, there are exceptions and Merlin Law Group can help discover these and work with you to receive coverage.

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