Orlando Harmon
Medical insurance is a complex and often confusing topic, and it's not uncommon for people to encounter issues with their insurance company not paying for certain medical services. When this happens, it's important to understand your rights and options. You may be able to resolve the issue by contacting your insurance company and requesting an explanation, or you may need to take further steps such as filing an appeal or disputing the charges. Understanding how insurance billing works and knowing your protections can help you navigate these situations effectively and avoid unexpected medical bills.
| Characteristics | Values |
|---|---|
| If the insurance company denies the claim | Contact the insurance company to ask for a detailed explanation of the denial |
| Call both the health plan and the medical office, and if possible, get them on a conference call | |
| Contact the insurance company to understand if the healthcare provider is in your insurance plan's network | |
| If the charges are disputed, you have the right to an "internal appeal" and an "external review" | |
| Contact your state's Department of Insurance for help | |
| Check if you are eligible for Medicaid or a subsidy to lower the cost of Marketplace insurance | |
| If the provider is in-network, submit the claim directly to your insurance company | |
| If you are eligible for financial assistance or "charity care", you may receive free or discounted health care to pay your medical bills |
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What You'll Learn
Understand your rights and protections
If you have health insurance and have needed medical care, you may have experienced a situation where the company won't pay. They may deny the full amount of a claim or most of it. However, there are things you can do.
Firstly, you should understand why your claim was denied. There could have been an error, such as incorrect billing codes or inconsistencies in the claim. Your insurance company may have also interpreted a clause in your policy differently from the way you understand it. If the ruling doesn’t sound fair, there’s a chance that it isn’t. Contact the insurance company to ask for a thorough explanation of the denial. Call both the health plan and the medical office, and if possible, get them on a conference call.
If your insurance agent or HR department can't help resolve your problem, call the health plan yourself. Be polite but persistent, and keep going up the corporate ladder. Make a detailed record of all phone calls, including the names and positions of everyone with whom you speak, as well as the call reference number. Follow up each call with a brief letter stating your understanding of the conversation, and request a written response within 30 days. Begin with the person who denied your claim, then write to the person’s supervisor. Include your policy number, copies of all relevant forms, bills, and supporting documents, and a clear, concise description of the problem. Request that the insurer respond to your questions in writing and keep copies of all the correspondence.
You have the right to an appeal with your health insurance company, including an "internal appeal" and an "external review" of the charges. Check your health insurance policy documents and the “explanation of benefits.” You can also dispute a medical bill with a debt collector or a credit reporting company. The No Surprises Act (NSA) protects you from “surprise billing” if you have health insurance and provides some protections from surprise medical bills even if you are uninsured. If you’re insured, the law bans certain practices, like requiring you to pay out-of-network charges for emergency services. However, some services, such as ground ambulance transportation services, are not protected by the NSA.
Financial assistance programs, sometimes called “charity care,” provide free or discounted health care to people who need help paying their medical bills. The Affordable Care Act (ACA) requires hospitals with 501(c)(3) nonprofit status to have programs to provide this care. Some states have charity care laws that also require additional free or discounted care to be provided by hospitals.
If you are unable to resolve your billing dispute to your satisfaction, you have several options. Many states provide help for consumers experiencing problems with their health insurance. State agencies such as your state attorney general and state insurance department or insurance commissioner may also offer helpful information as well as a complaint process.
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Contact your insurance company
If your medical insurance claim has been denied, there are several steps you can take to resolve the issue. It is important to first understand why the claim was denied and whether there may have been an error. Contact both the health plan and the medical office to discuss the denial, and request a thorough explanation. It is crucial to confirm whether the healthcare provider is in your insurance plan's network, as insurance companies can have multiple plans with varying provider networks.
If the issue cannot be resolved with the healthcare provider, you should then contact your insurance company. Be polite but persistent, and keep detailed records of all communication, including names, positions, call references, and follow-up letters. Request a written response within a specified timeframe, and include all relevant documentation. Ask for clarification on the denial and whether there has been a misinterpretation of your policy.
You have the right to an internal appeal and an external review of the charges. Check your policy documents and explanation of benefits to understand your rights and protections. If you are unsure about what your plan covers, your insurance company should be able to provide clarity.
In some cases, you may be protected from unexpected out-of-network charges ("surprise bills") by legislation such as the No Surprises Act (NSA). This law bans certain practices, such as requiring you to pay out-of-network charges for emergency services. However, it is important to note that not all services are protected under the NSA, and you may need to consult with your insurance company to understand your specific protections.
If you are unable to resolve the issue with your insurance company, you can seek assistance from consumer advocacy programs, state agencies, or the state insurance department or insurance commissioner. These entities may offer helpful information and a complaint process to address your concerns.
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Verify your healthcare provider is in your insurance plan's network
When you visit a healthcare provider within your insurance plan's network, you benefit from the negotiated payment rates that the insurance plan and doctor have agreed upon. This translates into lower costs for you. Therefore, it is important to verify that your healthcare provider is in your insurance plan's network.
Most insurance companies have provider search functions on their websites, allowing customers to find doctors that are in-network for their plans. However, networks can change daily, so the provider database may not always be up-to-date. Sometimes, only the doctor's medical group, and not the individual provider names, is listed as in-network. Therefore, it is a good idea to call your insurance company to verify that your healthcare provider is in your network. Reach out to your plan's member services team to get help with any questions about your plan.
If you are a HealthPartners member, you can find an in-network provider through your online account or the HealthPartners mobile app for iOS and Android.
Additionally, you can use price transparency tools provided by most insurance carriers to estimate your out-of-pocket expenses for both in-network and out-of-network care. These tools can help you make informed decisions about your healthcare choices and ensure you are getting the most out of your insurance plan.
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Appeal the charges with your insurance company
If your medical insurance claim has been denied, you have the right to appeal the charges with your insurance company. This can be done through an internal appeal and an external review.
Internal Appeal
An internal appeal must be filed within 180 days (6 months) of receiving notice that your claim was denied. If your appeal is for a service you haven't received yet, the internal appeal must be completed within 30 days. If it is for a service you have already received, the appeal must be completed within 60 days. During this process, you may ask your insurance company to conduct a full and fair review of its decision. If your case is urgent, the insurance company must expedite the process. At the end of the internal appeal, the insurance company must provide a written decision.
External Review
If your insurance company denies your claim after the internal appeal, you can file for an external review. This means that the insurance company no longer has the final say over whether to pay a claim, as the appeal is taken to an independent third party for review. In urgent situations, you can request an external review even if the internal appeal process is not complete.
Steps to Take
- Keep copies of all information related to your claim and the denial, including Explanation of Benefits forms, letters, and any other relevant documents.
- Make notes and keep records of any phone conversations with your insurance company or doctor that relate to your appeal, including the day, time, name, and title of the person you spoke to.
- Contact the insurance company and request a thorough explanation of the denial. Be polite but persistent, and keep going up the corporate ladder.
- Follow up each call with a letter stating your understanding of the conversation and request a written response within a specified time frame.
- If necessary, initiate the internal appeal process by sending your insurance company the original request and any supporting documents.
- If the internal appeal is unsuccessful, proceed with the external review process by following the instructions provided by your insurance company.
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Seek financial assistance or charity care
If you are unable to pay your medical bills, you can seek financial assistance or charity care. Financial assistance programs, sometimes referred to as "charity care," offer free or discounted healthcare to those who require assistance in paying their medical bills. These programs are often offered by hospitals, states, non-profit organisations, or advocacy groups.
The Affordable Care Act (ACA) mandates that hospitals with 501(c)(3) non-profit status must have financial assistance programs in place. Additionally, some states have enacted charity care laws that require hospitals to provide additional free or discounted care. For example, Washington State's charity care law mandates hospitals to offer financial assistance to low-income patients struggling with out-of-pocket medical expenses. It is important to note that charity care is not limited to uninsured individuals and can also benefit those with insurance who face significant out-of-pocket costs.
To determine your eligibility for financial assistance or charity care, contact the hospital and inquire about their policies and requirements. Hospitals are legally required to notify patients about the availability of charity care and assess their eligibility before seeking payment for out-of-pocket expenses. You can also refer to the IRS website for more information on charity care and financial assistance policies.
While navigating medical bills and insurance can be challenging, it is crucial to be cautious when using credit cards or medical credit cards to settle outstanding balances. High-interest rates and a loss of negotiating power may result from this decision. Instead, consider exploring interest-free repayment plans or seeking assistance from state agencies, such as the state attorney general or state insurance department, which can provide valuable information and complaint processes.
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Frequently asked questions
First, make sure that you owe the bill. You could have already paid it or the provider may have confused you with someone else. If you are unable to pay, you can take steps to make sure that the medical bill is correctly calculated and that you get any available financial or legal help. You can also dispute a medical bill with a debt collector or a credit reporting company.
The No Surprises Act protects you from "surprise billing" if you have health insurance and provides some protections from surprise medical bills if you are uninsured. For example, if you are insured, the law bans certain practices, like requiring you to pay out-of-network charges for emergency services.
If you disagree with the charges or want more information, you have the right to an appeal with your health insurance company, which can take the form of an "internal appeal" or an "external review" of the charges. Check your health insurance policy documents and the "explanation of benefits" to learn more.
The premium payment grace period is usually 3 months if you have taken a tax credit in advance to lower your monthly health insurance payment. During this time, you must pay all owed premiums to avoid losing your coverage.
If you receive a bill indicating that a claim was denied, make sure you fully understand why before paying. Call both the health plan and the medical office to discuss the issue. If your insurance agent or HR department can't help resolve the problem, call the health plan yourself and be polite but persistent.
