When Your Health Insurance Plan Wont Pay

The very nature of managed care health insurance plans increases the likelihood of a legitimate health insurance claim being denied. Bear in mind that managed care (health maintenance organizations, or HMOs, and preferred provider organziations, or PPOs) exist for the purpose of controlling costs for the health insurance company. Many health care procedures, surgeries, durable medical equipment and drugs, particularly the more expensive ones, require prior authorization from the health insurance plan before the plan will pay. Claims are reviewed to determine "medical necessity" of the claim. Health care services or products deemed "not medically necessary" will almost certainly be denied for payment by the health insurance plan.

Health insurance companies do make mistakes, however, and it's certainly possible that a covered expense will be denied. What recourse does the health plan member have when one disagrees with the decision of the health plan? Here are some steps to take in dealing with a denial of payment.

1. Review the explanation of benefits (EOB) sent to you from the health insurance company. The EOB should state what services or goods were billed and briefly why benefits were denied.

2. Review your particular health insurance policy. What benefits does the health insurance policy state for the particular service or product? Should the claim be covered according to the policy?

3. Does the health plan have special criteria to be met in order for an particular expense to qualify as "medically necessary" and be considered a covered expense? For example, many managed care plans will cover drugs on their formulary. Other, nonformularly drugs may not be covered at all, or may be covered only if the formulary drugs have been tried and failed. An expensive MRI procedure may only be covered if certain symptoms are present. Check your policy to determine whether the expense qualifies as "medically necessary" by the health insurance company. Your health care provider must submit sufficient documentation to the health insurance plan to justify the need for the expense.

4. Is the health care provider "in-network" (contracted) with your health insurance plan? If not, does your managed care plan cover "out-of-network" (non-contracted) providers? Most HMO plans do not cover "out-of-network" providers; many PPOs will pay for services by "out-of-network" providers, but usually at at lower rate than paid to "in-network" providers.