Insurance denials are a real pain, but they are an important issue worth addressing. As a physician deeply invested in providing quality care, I see the frustrations my patients face when insurance companies deny their claims. It's disheartening, especially when many of these denials seem arbitrary and unnecessary.

Understanding Out-of-Network Benefits

In my practice, I often receive letters from insurance companies denying claims for my patients. Although I run an out-of-network practice and do not bill insurance companies directly, I provide detailed receipts with all the necessary information for patients to submit claims to their insurance companies. Despite these efforts, I see denials daily.

It's important to understand that going to an out-of-network doctor does not mean your care is any less legitimate. I bill as a physician, and there is no reason why these visits shouldn't be covered, at least partially, if patients have out-of-network benefits.

Meeting Your Deductible

One common issue is that patients often misunderstand the terms used by insurance companies and what they mean.  For instance, I’ve had patients contact their insurance prior to seeing me, give the insurance company the codes I will use, and they will be told that the visit will be covered.  Then the patient receives zero reimbursement and is confused and angry.  I’ve seen this occur when a patient hasn’t yet reached their personal or family deductible. 

In this situation, the service is “covered” and the patient’s payment will be applied to their deductible but they will not receive any reimbursement because there won’t be any reimbursement until the deductible has been met.  Sometimes people mistakenly interpret this as a denial.  While it is not truly a denial, it is confusing and leads many people to feel misled and frustrated when they have already paid for a service expecting to get money back from the insurance but don’t. 

Why Insurance Companies Deny Claims

Unfortunately, true denials are very common as well.  I see many claims get denied for reasons such as “missing information” or needing the physician’s information sent on a specific form. Usually, this information (like one of my medical ID numbers) is readily available with a quick Google search or is written clearly on the itemized receipt we have already provided. This is a tactic that can wear down even the most diligent of patients.  I strongly suspect that these claims are denied automatically with the hopes that patients (and/or doctors) will simply give up either due to lack of time and patience or due to not understanding the process and that they could still get the reimbursement if they just push a little harder. 

In 2023, ProPublica uncovered an algorithm used by Cigna Health Insurance to allow automatic denials due to medical necessity without actually reviewing the medical cases.  I suspect this is happening in a variety of forms by many insurance companies, and they get away with it because patients are too confused or simply too tired to look into it any further, especially when the claims are for smaller amounts of money.  But those small amounts add up over time – making the insurance companies millions of dollars and denying reimbursement to thousands of patients who are paying monthly premiums to cover the costs of their care. 

The Importance of Persistence

This situation is frustrating and unfair. If you're paying for insurance and have out-of-network benefits, you deserve to be reimbursed or to have those expenses applied to your deductible as promised in your contract with the insurance company. It's disheartening to see patients give up on getting reimbursed simply because the process is cumbersome or confusing.

I urge you not to give up when faced with an insurance denial or the lack of reimbursement is surprising or doesn’t make sense to you. Reach out to your doctor for assistance, consult the billing department where you received care, or directly contact the insurance company to clarify what's needed. It's worth the time and effort to get the reimbursement you're entitled to.

Advocating for Your Health and Well-being

Healthcare is a complex and often overwhelming system, but your health and well-being deserve attention and respect. Don't let insurance denials discourage you from seeking the care you need or from fighting for the reimbursement you deserve. Remember, you are not alone in this process, and there are resources and people who can help you navigate these challenges.

My goal is to ensure that you receive the best possible care without unnecessary financial burdens and can enjoy your baby and family instead of worrying about medical costs. Advocating for yourself and staying persistent in the face of insurance obstacles is essential. If you are my patient and have received insurance denials that you suspect are not warranted, please reach out to me so I can help you navigate the process and get reimbursed the money you are owed.

I’m always on your side.