Receiving a medical bill is stressful enough, but discovering your insurance won’t cover it is overwhelming. Many people face this situation, but you have options and a clear path to challenge the decision. We’re explaining what to do if insurance isn’t covering medical expenses, how to appeal their decision, and manage the costs.
Review Your Explanation of Benefits
Before you take action, carefully read the Explanation of Benefits (EOB) from your insurer. This document outlines what the insurance company paid, what it didn’t, and why.
Also, the reason for the denial is important to note. It could be a simple coding error, a service deemed not medically necessary, or an issue with your plan’s coverage limits. The specific reason for denial is the first thing you need to begin building your case.
Gather Your Medical Records and Documentation
Once you know why they denied your claim, collect all relevant documents to support your appeal. This might include the following documents:
- A copy of the denied claim and your EOB.
- The original bill from your healthcare provider.
- Your complete medical records related to the treatment.
- Letters from your doctor explaining why the service or item is medically necessary.
- Any other correspondence with your insurance company.
Organized and thorough documentation strengthens your position and shows you are serious about your appeal.
Appeal the Decision
Most insurance companies have a formal appeals process. Typically, you start with an internal appeal—ask your insurer to reconsider the decision. Submit your appeal in writing and include all the documentation you gathered. Clearly state why you believe the denial is incorrect and provide evidence from your doctor.
You can request an external review if the internal appeal fails. This means a third party will examine your claim and make a binding decision—it will be final. This step gives you an unbiased assessment of your claim. For expenses like hospital beds for the home, a detailed letter from your doctor explaining the necessity for recovery is very persuasive.
Explore Other Financial Options
While your appeal is in progress, you can explore other ways to manage the bill. Contact your provider’s billing department to ask about negotiating the cost.
Many hospitals offer discounts for patients who can pay a portion upfront or are willing to set up a payment plan. You can also research patient advocacy organizations or financial assistance programs that may cover the costs of your medical care.
Facing a denied insurance claim is no small thing, but you have the power to fight back. Start by understanding the denial, gathering your evidence, and following the appeals process. By taking these proactive steps, you can increase your chances of getting your medical expenses covered by insurance and not your 401(k).
