Insurance companies are playing the odds, patient advocates say. They are counting on people not having the stamina to challenge every denied claim, even when there's a valid medical reason for a drug or treatment being covered.
"It's intimidating," said Betsy Imholz, special projects director for Consumers Union. "It's hard to understand the process and many people feel that the default answer from insurers is no."
Today I'll provide some tips on jumping through the many hoops the insurance industry might throw your way if you choose to appeal a denied claim.
While the appeals process is time-consuming and frustrating, it's often worth putting up a fight. A 2011 study by the Government Accountability Office found that for the relatively small percentage of denied claims that were challenged, about half ended up being reversed.
The insurance industry insists that denials result from a rigorous process of evaluating the medical soundness of prescribed drugs or treatments.
However, the GAO report said many denials can be traced to billing errors or missing information. Something as simple as an incorrect code submitted by a doctor's office can trigger a denial.
The bottom line is that it's entirely possible you will be able to get a denial reversed. But you will have to be thorough and diligent.
"Insurers make money when you pay in through premiums and copays, and they lose money when they pay out," said Chuck Idelson, a spokesman for the California Nurses Association, which supports a Medicare-for-all insurance system.
