The Most Common Health Insurance Denials

Patient Balance Issues	Click here to order
1. Balance billing by the medical provider 2. Negotiate the balance owed with your physician 3. Cash Pay negotiations (don't pay full charge)	Mistakes are often made by the Physician or his/her medical billing office. If you were balance billed for the difference between your contracted health plan and the amount of the payment, this is incorrect. If you pay cash or owe a significant amount, attempt to negotiate a discount or payment plan. For more information click here
Usual and Customary/Out of Network Denials	Click here to order
1. Usual and Customary Reductions 2. Patient received unexpected bill by an out of network physician	This is probably the most common concern among patients. When a patient goes to a hospital which is contracted with their health plan and feel everything was taken care of, but then they receive out of network bills from the anesthesiologist, pathologist, radiologist, assistant surgeon and so on, which are reduced in payment due to Usual and Customary. For more information click here
Health Plan Denied the Claim due to Medical Necessity	Click here to order
1. Denial due to lack of medical necessity 2. Experimental/investigational denials 3. Cosmetic denials	A significant number of claims denials are related to medical necessity, or the lack thereof. The health plan is essentially saying that the physician or medical provider that treated you did so without a justifiable medical reason, or that it was cosmetic, experimental, or investigational. But, your physician may know best and if your physician properly documented his/her treatment of you in your medical chart, then this should always be appealed. For more information click here
Authorization Denials for Specialists	Click here to order
1. Non participating services received without a referral or authorization 2. Non participating provider denial	Some health plans, especially HMOs, limit the availability of Specialists to their members, unless they seek an authorization or referral from their primary care physician. This is done so that Specialty Care is not overused or used unnecessarily, as the cost of Specialty Care is expensive. For more information click here
Emergency Room Denials	Click here to order
1. The health plan denied the Emergency Room visit 2. The health plan denied the transportation to an Emergency Hospital 3. The health plan did not authorize the emergency visit	Physicians and their billing offices must input all of the billing data into their billing system in order to submit a claim to your health plan. During this process, a physician who may have been extensively trained in practicing medicine, may not have been as trained on preparing a bill to the health plan. As a result, mistakes may occur in the preparation and billing of your claim. For more information click here
Weight Related Surgical Denials	Click here to order
1. The health plan denied a lap band surgical procedure 2. The health plan denied a gastric bypass surgical procedure 3. The health plan denied an abdominoplasty	Health plans do not want to approve a claims payment for medical procedures that they feel are not medically necessary or potentially cosmetic in nature. The method of appealing these are to specify medical reasons of why the surgical procedure is required. For more information click here
Timely Filing Denials	Click here to order
1. The health plan denied a claim that was billed on time 2. The health plan denied a claim that was not billed on time	One of the most common health insurance claim denials are those that are denied for being submitted late. These can be appealed and won. Some of the claims may be denied in error and you would need proof of the original claim submission to appeal. For more information click here
Denials Related to Prescription Drugs	Click here to order
1. Drug is not on the health plan's formulary 2. The health plan denied authorization for prescription drugs 3. The health plan did not pay adequately compared with AWP	Health Insurance Companies have noticed a significant increase in the payments they have made towards Prescription Drug claims. With this in mind, Health Plans have had to be creative in how they attempt to cost contain this benefit coverage. For more information click here
The Health Plan Processed the Claim Incorrectly	Click here to order
1. The health plan paid the incorrect amount 2. The health plan paid the wrong person or medical provider	Today, many claims payments are made automatically, but still quite a large number of them are processed manually. Due to this manual processing there are opportunities for making a mistake. Some health plans have a better quality rating than others. While one health plan accepts only a 2% error rating, other health plans may be ok with a 20% error rating. For more information click here
The Physician/Medical Provider Billed the Claim Incorrectly	Click here to order
1. The wrong diagnosis, procedure code or place of service was billed 2. The wrong modifier or lack of modifier was billed 3. The claim was billed without a provider number	Physicians and their billing offices must input all of the billing data into their billing system in order to submit a claim to your health plan. During this process, a physician who may have been extensively trained in practicing medicine, may not have been as trained on preparing a bill to the health plan. As a result, mistakes may occur in the preparation and billing of your claim. For more information click here
The Claim Denied due to Policy Limitations/Guidelines	Click here to order
1. An authorization was not obtained 2. The claim was filed late, causing a timely filing denial 3. The claim was appealed late, causing a timely follow up denial 4. The claim was denied due to pre-existing 5. The claim was denied due to a duplicate claim previously billed 6. The benefit maximum was already paid 7. The claim was denied as it was a non-covered benefit 8. Lack of information caused the denial	One of the most frustrating denials and a type of denial usually overlooked, are those that are stated in a policy booklet, but not read by the patient or insured. Individuals, prior to receiving an expensive medical treatment or have a lengthy hospitalization should always read the policy booklet to check first, if the medical procedure/service is a covered benefit, and second, to identify if there are any policy limitations or guidelines that must be followed in order for that service to be paid. For more information click here

common health insurance denials
The Most Common Health Insurance Denials by Category