What Are the Reasons Behind Health Insurance Denials?

When it comes to health insurance, there are a number of reasons why a claim may be denied or coverage canceled. Insurers need to explain to you why they denied your claim or canceled your coverage. Common reasons for denial include experimental treatments, technicalities, and lack of prior authorization or referral. Insurers also use auditing software, often referred to as “denial engines”, to reduce the amount of money paid to doctors and hospitals.

Government plans are based on medical need, and several plans with a high volume of denied requests reported a much higher proportion of refusals based on medical necessity. Health insurance companies cannot deny you coverage or charge you more simply because you have a “pre-existing condition”. Reporting stronger transparency data could provide useful data for both regulators and consumers. The McKennon Law Group P.

C. regularly publishes articles on its California insurance litigation blog that cover related topics in a series of articles on bad faith insurance, life insurance, long-term and short-term disability insurance, annuities, accidental death insurance, ERISA, and other areas of the law. State insurance regulators can sanction health insurers who deny claims inappropriately. In addition, many large health insurance companies have been accused of illegally and retroactively canceling the policies of people whose conditions are costly to treat.The government plans to report denial of medical necessity separately for behavioral health services and all other services.

Connecticut regulators require health insurers in all market segments to submit annual data on claims payment practices and other measures. Among 2% of complaints identified as denials due to medical necessity, 1 in 5 were for behavioral health services.If your insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. You can ask your insurance company to reconsider its decision. It should be noted that they count on people not having the energy to challenge all denied claims, even when there is a valid medical reason to cover a medication or treatment.