Why Was My Medical Claim Denied?

It can be very scary and upsetting to receive an unexpected medical bill. Sometimes they can be small, confusing and just frustrating. Sometimes they can be large and frightening. Let’s talk about some of the most common reasons your medical claim may be denied. 

Screening to Diagnostic

Screening services are usually covered at no charge. Meaning you will have a $0 copay. But sometimes something might pop up in a routine screening that could cause the physician or billing department to change the procedure from screening to diagnostic. Or they might run an additional test in the moment. 

For example, you might take your child into a wellness visit at their pediatrician which would be considered routine screening. But if the doctor notices your child’s throat is a little red, they might order a strep test. Or, if they are not meeting their milestones, they might refer your child to some type of specialized therapy. All of a sudden, you’ve gone from a screening to a diagnostic visit.

We’ve also encountered clients who went in for a routine mammogram only to have their bill switched from screening to diagnostic based on the results of said mammogram and recommendations to return for additional testing.

Sometimes this is intentional. Sometimes it could be a miscommunication between the doctor and the billing department. Contact your doctor and your insurance carrier to resolve this type of medical claim. 

Coding Error

Another extremely common issue is improper medical coding. The billing department may simply make an error and switch a number or letter in a code. This could entirely change the nature of the procedure you and your insurance are billed for. If you spot this denied medical claim in your explanation of benefits, contact your insurance carrier immediately. You’ll need to explain the treatment or service you actually received. They should be able to contact your doctor’s billing office to resolve the issue.

The statistics regarding medical billing errors are all over the place, but one study indicates that 80% of medical bills may contain one or more error. Please always double and even triple check all bills and explanation of benefits. Do not just pay blindly. They may contain errors. Additionally, medical fraud (especially medicare fraud) are much more common than you might think.

Not Medically Necessary

Another extremely frustrating reason for receiving a medical bill or having a medical claim denied is when your insurance carrier deems a service or treatment “not medically necessary”. There can be a few reasons for this.

1. Preauthorization

We see this in medicare advantage plans A LOT. When you have an HMO you need a doctor’s referral to see a specialist. But even more than that, your insurance must pre authorize you to see the specialist or receive certain treatments. Without this preauthorization, you may be denied. You will need your doctor to provide a letter or documentation explaining why this is medically necessary. This can be extremely frustrating. This is one of the many reasons that medicare supplement plans are more popular than Medicare Advantage: no referrals and no pre authorization

2. Inappropriate setting 

Your carrier may also determine that a treatment or service could have been better provided by your PCP or urgent care rather than an emergency room. Sometimes something may feel like an emergency and quite frankly it is better to err on the side of caution. Should this happen, again you will need to show why this was a medical necessity or emergency. 

Out of Network

If you have an HMO, you will need to operate within a network of doctors and hospitals. If you go out of network you will be billed for it. If you need a referral from a doctor, make sure to remind them that you need a specialist who accepts your insurance. Often patients go home to call for an appointment only to discover that their specialist does not take their insurance.

Now in the case of a true medical, you should still head to the closest hospital. Under the affordable care act, your insurance provider cannot charge you more for an out of network emergency room than in an in network emergency room in a medical emergency. 

Surprise Medical Bill Ban

Prior to 2022 and the Surprise Medical Bill Ban, you could still receive a balance bill from the facility. Also, if you went to an in network hospital but were treated by an out of network physician, you could receive a bill. These instances are no longer permissible, so if you receive a bill, please contact your insurance carrier to dispute it.