Sooner or later, you’ll likely have to file a health insurance claim.
You may think it’s a straightforward process that involves calling your insurance company or filling out a claim form on its website, but even when you do what’s asked of you, things don’t always go as planned: You may get denied!
Money expert Clark Howard says you should try to appeal a denial of an insurance claim immediately, but he warns it’s typically difficult to do.
“With health insurers, let me tell you how clear an appeals process is: Clear as mud,” Clark says. “And the whole game with the health insurers is to ignore your appeal.”
In this article, we’ll share some steps from Clark on what you need to do if your insurance claim is denied.
Your Health Insurance Claim Is Denied: What Next?
One online source says that 2023 is the year of claim denials.
According to an Experian Health survey of 200 hospital professionals and organizations, 73 percent of respondents said that claims are denied between 5 to 15 percent of the time. And nearly one in three see declined claims 10 to 15 percent of the time.
File an Appeal
When your health insurance denies your claim, the first thing Clark wants you to do is file an appeal.
“So you get a denial from a health insurer saying that a procedure was not authorized or they disagree with it,” he says. “It could be a lab test, who knows what. You try to appeal.”
“Most people just say, ‘Ah well,’ and they pay the bill out of pocket. What I want you to know is, don’t be a wallflower. Don’t just say, ‘Well, they’re not going to pay.’ Uh-uh. You need to get started with appeals.”
It’s very possible that the insurer will require that you file tedious paperwork or even fax a document over to them. Clark says you need to be diligent in following the appeal instructions.
“Start by humoring them,” he says. “And if they tell you that you have to fax paperwork in, figure out how to fax.”
Tip: Try ProPublica’s Claim File Helper
Document Your Appeals Process
Clark says it’s important to keep immaculate records when dealing with an insurance company. Once you send in your appeals paperwork, make sure it’s timestamped in some way (sending an email will do this, and even a fax will too).
If you don’t record when you sent the documents, the insurers may try to use that against you.
“The big game insurers play is that you then don’t hear from them and then you call them up and customer no-service says, ‘We show no record of us receiving this,’ and so you humor them and send it in again,” Clark says.
Contact Your State Insurance Department
As an alternative to reaching out to your insurer directly, you can contact your state’s insurance department.
“With the state insurance department, you can file a complaint against an insurer and that sends it in a different way to the insurance company and then suddenly, ‘Oh, we see your complaint.’ It doesn’t mean you’ll win, but it gets you a hearing,” he says.
The National Association of Insurance Commissioners (NAIC) website has a list of state insurance departments you can go through to find yours.
Use Alternative Tactics
Try Social Media
“Alternative tactics mean social media, where you’re talking about it online,” Clark says.
Sometimes, companies will be more apt to respond via social media than they will through a phone number or email address you find on their website.
Of course, when talking to customer service via social media, Clark always wants you to play nice. Never come off as rude or fly off the handle.
You can also try to go through your employer’s human resources department to get a listening ear with an insurance company.
“See if you can get what they usually call an executive contact at the insurer and see if you can get to someone who will actually look at your situation,” Clark says. “You may need documentation from a specialist or a lab to provide to the insurer as part of the appeal.”
Don’t Give Up
It won’t be cheaper, but it may be easier and less time-consuming to throw in the towel and pay the bill that your insurance company wants to pass onto you — but you’ve got to be persistent.
“If you keep trying different angles, odds go up and up and up that a claim that was denied will in fact be processed,” Clark says. “The problem here is that most people flat-out give up. Don’t give up.”
Filing an appeal to a health claims denial may take a lot of time and effort on your part, but if you can save money on health care, it will be worth it. Because of the nature of the insurance industry, Clark says it will take a multi-pronged approach.
“There is no roadmap,” he says. “Remember, it’s a whole cynical process by the insurer. What you have may be perfectly valid, or it may be in a gray area. And they’re going to deny it and make it opaque and make it nearly impossible for you to know how to fight back, so you’ve got to use every strategy you can.”
Want more money-saving tips? Read our guide on how to save on prescriptions.