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Arguments To Use Against An Insurer's Denial Of A Health Claim

A Claim Denied On The Basis That The Specialist Or Facility Is Out Of Network

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7/11

If a health insurance policy does not cover medical care provided outside the company's network, what to do in an appeal depends on whether you received the care on an emergency basis or whether you received the care without your active choice. Steps to take about each are described below.

If you actively chose to receive medical care by a doctor or facility outside the network and are now seeking payment, you will have to prove both that the care was "medically necessary" and that you were prudent in seeking such care instead of staying in network. Information about appealing denial of a claim because of "medical necessity" is described above.

Emergency Care

  • First check to see what your policy says about emergency care. It is not likely that emergency care will not be covered if you are traveling or if it would be medically unwise for you to take the time to go to an in network doctor or facility.
  • If there is such an exclusion, check your state law to see if the exclusion is legal.
    • To learn the law of your state, go to The Actors' Fund Of America's Health Insurance Resource Center (www.ahirc.org offsite link, click on your state, then click on "Insurance Guides" and/or Complaints/Appeals).
    • If you have difficulty, contact your Department of Insurance for guidance. For contact information for your state insurance department, see: www.naic.org offsite link. Click on "NAIC States and Jurisdictions."
  • If an exclusion is legal, ask your doctor to help you write a letter explaining why it was imperative that you receive care from the doctor and/or facility rather than than one which is in network,. Include what would have happened to you if you didn't seek the emergency care  you did.

Care Received Without Your Knowledge

It happens that you may receive a medical service, particularly from a specialist, without knowledge or when you are in no position to ask.. For instance, you engage a surgeon who is in network, but don't think to ask whether the anesthesiologist that will be used in the operation is also in network. Or you were unconscious.  This is generally referred to as "Balance Billing."

In this situation, insurer's pay part of the fee, or none of the fee at all. The patient is billed for the difference.

If this happens to you, take the following steps:

  • Step 1. Check to see if you are being billed by a health care provider who is in your network for a service that is covered by your insurance plan. If so, the insurer should pay the bill.
  • Step 2. If the bill is from a doctor not in the network, contact the insurance company. Explain that this was an involuntary use of an out-of-network provider, and that you made a good faith effort to only use in-network doctors. Ask the insurance company to pay the bill.
  • Step 3. If the insurance company will not pay the bill, check the law in your state. It may prohibit balance billing.
    • To learn the law of your state, go to The Actors' Fund Of America's Health Insurance Resource Center (www.ahirc.org offsite link, click on your state, then click on "Insurance Guides" and/or Complaints/Appeals).
    • If you have difficulty, contact your Department of Insurance for guidance. There may be a regulation which prevents balance billing in your situation. For example, in California, there is a regulation which makes it illegal for people covered by an HMO (Health Maintenance Organization) to be balance billed for out-of-network emergency servivces. If there is such a law/regulation in your state, call the insurance company and the doctor and remind them of it. For your state's insurance department contact information see: www.naic.org offsite link. Click on "NAIC States and Jurisdictions."
  • Step 4. If there is no such law or regulation in your state, don't pay the bill and expect to get it back from the insurance company. Instead, ask the company to work through the situation on your behalf to eliminate or reduce the bill. If the insurer won't try to negotiate the bill, contact the doctor or his or her staff and try to negotiate the bill, or hire a professional to do the negotiation for you.
  • Step 5. If there continues to be an outstanding bill, file an appeal with your insurance company to get the company to pay all, or at least a large part, of the bill. The explanation should include the steps you took to follow the insurer's rules. 
    • If the doctor was engaged by another doctor, Include a statement that you assumed the in network doctor knew the rules and that he or she would only use other doctors who were also in network. If the use of the lead doctor was pre-approved by the insurer, include that fact as well.
    • If the use of the doctor was involuntary, include the facts about what was going on. Include proof of what was happening at the time. For instance, if you were in an ambulance, a copy of the report from the ambulance company. 

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