By Jonathan M. Clark

You did everything right. You paid your premiums, scheduled
with an in-network doctor, and followed all the recommendations. Maybe you even
got pre-approval.

Even after all that, the insurance company denied your claim.

If this is your situation, you are not alone. 15% of claims
are initially denied. (source) This means you one of millions of Americans
suffering this same setback.

This article will explain why healthcare claims are denied
and what to do instead.

The Top Reasons Health Insurance Claims Are Denied

1. Lack of Pre-Authorization

Your insurance plan likely requires pre-authorization for
specific procedures, medications, and specialist visits. If your doctor doesn’t
seek pre-authorization or it doesn’t meet the criteria, your insurance company
will not cover it.

2. Out-of-Network Doctor

Your coverage will be limited or denied entirely if your
doctor isn’t in the network.

3. Administrative Errors

Sometimes, a denial simply comes because a form wasn’t filled or filed correctly.

4. Medical Necessity Not Proven

Doctors are medical experts who undergo rigorous training, but insurance companies do not simply take their expert opinion. Instead, they have internal criteria to determine what is “necessary” and what isn’t. This can be an extraordinarily frustrating reasoning for denial.

5. Policy Exclusions

This is the number one reason by far. Most of these fall under elective procedures and those deemed to be cosmetic. You might also have coverage excluded if you are seeking mental health services or alternative treatments, although this situation is changing.

6. Policy Change

If your insurance company changes policies, you might be surprised to find that procedures or treatments that were once covered no longer are. And unfortunately, you might find that out by receiving an
unexpected bill.

7. Missed a Deadline

If paperwork isn’t submitted within a certain timeframe, even claims that fall under coverage will be denied.

The Full Cost of Claim Denials

Before we look at how to avoid claim denials, we need to fully understand their cost. This includes and goes far beyond finances.

Surprise Bills

The most obvious issue? Surprise bills. These can ruin your financial planning, even when you thought you had everything accounted for.

Even a simple test or ER visit can run thousands of dollars.
For most people, that cost would be devastating. After all, 57.4% of Americans
have less than $1,000 in savings. (source) A surprise medical bill can
completely wipe out the resources of most households.

Stress

Probably the biggest non-financial burden to claim denials is stress. Receiving a jargon-filled letter rejecting your claim leaves you with questions. What will happen now? Did you do something wrong? How do you fix this?

If you choose to appeal the denial, you will experience even more stress as you manage new deadlines, complicated paperwork, and the possibility of further rejection.

Delays in Care

When insurance denies your claim, you might have to entirely rethink your course of treatment. You might need to change the specialist you see, which means getting a referral from a new doctor. Or maybe you’ll have to start getting treatment in a nearby city.

All of these moves lead to delays in care. And even short delays can lead to worsening conditions and more anxiety.

Escape the Health Insurance Denial Trap

Ultimately, you can’t escape denied claims if you stay inside the insurance system. It is a for-profit system that makes money by
denying as many claims as possible.

The only way out is to move to a community-based system.
That’s how CrowdCare makes health coverage simple, affordable, and highly
flexible.

Let’s look at each of the top reasons for a denied claim to
see how CrowdCare work differently.

●              Lack of Pre-Authorization: No pre-authorization is required with CrowdCare.

●              Out-of-Network Doctors: CrowdCare allows you to go to any doctor or specialist. There is no network to be inside of or outside of.

●              Administrative Errors: All the paperwork is done through an easy-to-use app. Simply upload a picture of your bill, and you’re done.

●              Medical Necessity Not Proven: If your doctor considers it medically necessary, so does CrowdCare.

●              Policy Exclusions: Treatments not included in coverage are straightforward. They include cosmetic treatments, long-term prescriptions, and fertility treatments.
For the first two years of membership, you cannot include treatments for
pre-existing conditions.

●              Policy Change: As a community, members are always updated with policy changes. And the rare changes are simple because the policies are simple.

●              Missed a Deadline: Using the app, submitting bills for approval takes a minute, removing stress and difficulty meeting deadlines.

Ditch the Insurance and Ditch the Denied Claims

Denied claims cost money and cause stress, but you don’t
have to experience them.

CrowdCare offers a new way forward, one where community
cost-sharing simplifies everything.

Learn more about CrowdCare here.