You went to the doctor. The doctor said you needed treatment. You got the treatment. Then insurance sends a letter: "Claim denied."

Your first reaction is probably rage. Your second is panic about the bill. But here's what most people don't know: Most denied claims can be overturned if you know how to fight back.

Reality Check: According to the AMA, about 1 in 7 claims gets denied initially. BUT studies show that 60-80% of appealed denials get overturned. That's right - the insurance company is WRONG most of the time.

Why Claims Get Denied (The Real Reasons)

1. "Not Medically Necessary"

Translation: "We don't think you needed this." This is the most common denial and the easiest to fight if your doctor backs you up.

2. Coding Errors

Your doctor's office used the wrong billing code. This is a paperwork problem, not a medical problem. Easily fixable.

3. Prior Authorization Not Obtained

The doctor should have gotten approval BEFORE the procedure but didn't. Frustrating, but sometimes appealable.

4. Out-of-Network Provider

You saw a doctor outside your insurance network. Harder to fight, but possible in emergencies.

5. Pre-existing Condition (Rare Now)

This should be illegal under the ACA, but short-term plans still pull this move.

6. Plan Exclusion

The treatment is specifically excluded from your policy (like cosmetic procedures).

Important: Check your denial letter carefully. It MUST state the specific reason for denial. If it's vague, call and demand a detailed explanation. They're legally required to provide it.

Step-by-Step: How to Appeal a Denied Claim

Step 1: Read the Denial Letter (Actually Read It)

Look for:

  • The specific reason for denial (usually a code)
  • The deadline to appeal (usually 180 days, but varies)
  • The appeals process instructions
  • Contact information for questions
Pro Tip: Set a reminder for 30 days BEFORE the appeal deadline. Insurers are hoping you'll forget or give up.

Step 2: Call Your Doctor's Office FIRST

Before you do anything else, call your doctor's billing department and say: "My insurance denied this claim for [reason]. Can you help?"

Often they'll say: "Oh, we used the wrong code" or "We forgot to submit the pre-auth paperwork." They'll resubmit, problem solved.

Step 3: Gather Your Evidence

You're building a case. Collect:

  • Denial letter: Keep the original
  • Doctor's letter: Ask your doctor to write a letter explaining why the treatment was medically necessary
  • Medical records: Get copies of relevant records, test results, imaging
  • Insurance policy: Find the section that SHOULD cover this treatment
  • Research/guidelines: Find medical guidelines or studies supporting the treatment

Step 4: Write Your Appeal Letter

Here's the format that works:

[Your Name] [Your Address] [Policy Number] [Date] [Insurance Company Name] Appeals Department [Address from denial letter] RE: Appeal of Claim Denial - Claim #[Number] Dear Appeals Department: I am writing to appeal the denial of coverage for [treatment/procedure] performed on [date] by [provider name]. REASON FOR APPEAL: [State why the denial is wrong. Be specific.] MEDICAL NECESSITY: [Explain why you needed this treatment. Include your doctor's letter here.] POLICY COVERAGE: [Quote the section of your policy that SHOULD cover this. Example: "Section 5.2 of my policy states that diagnostic imaging is covered when medically necessary."] SUPPORTING DOCUMENTATION: I have enclosed the following: - Letter from Dr. [Name] explaining medical necessity - Medical records from [date] - [Any other relevant documents] I request that you overturn this denial and provide coverage as outlined in my policy. Please respond in writing within 30 days as required by law. Sincerely, [Your signature] [Your name]

Step 5: Submit Your Appeal

Submit through EVERY channel:

  • Online portal: Upload everything
  • Mail: Send certified mail with return receipt
  • Fax: Get a confirmation page

Keep copies of EVERYTHING you submit.

Step 6: Follow Up Relentlessly

Call every week. Ask for the status. Get names and reference numbers. Make them remember you.

Secret Weapon: If your first appeal fails, request an EXTERNAL review. This brings in an independent third party. External reviews overturn denials about 50% of the time.

When the Bill Can't Wait

If you're getting dunning notices from the hospital while appealing:

  1. Call the hospital billing department: Explain you're appealing the insurance denial. Most hospitals will pause collections.
  2. Request a payment plan: Even if it's $25/month. This stops them from sending you to collections.
  3. Apply for hospital financial assistance: Many hospitals have charity care programs. Doesn't hurt to ask.

When to Get Help

You should probably get professional help if:

  • The claim is over $10,000
  • Your first appeal was denied
  • The insurance company is being deliberately difficult
  • You don't understand the medical terminology or policy language

Your options:

  • Your insurance agent: We help with appeals all the time. It's part of the job.
  • Patient advocate: Some hospitals have these. They fight insurance companies for a living.
  • Attorney: For big claims, a health insurance attorney might take it on contingency
  • State insurance commissioner: File a complaint. Insurance companies HATE dealing with regulators.
David's Personal Rant: Insurance companies count on you giving up. They make the process confusing and exhausting ON PURPOSE. But remember: they're playing with house money. It's YOUR medical care and YOUR money. Don't let them win by default.

Preventive Strategies (So This Doesn't Happen Again)

  • Always get pre-authorization for expensive procedures, even if your doctor says it's not required
  • Verify network status of every provider before treatment
  • Keep records of all medical visits, treatments, and communications with insurance
  • Read your EOBs (Explanation of Benefits) - they're previews of potential denials

Bottom Line

Insurance denials feel personal, but they're usually just bureaucratic nonsense. The company is betting you won't fight back.

Prove them wrong:

  • Appeal EVERY denial that seems wrong
  • Get your doctor to back you up
  • Document everything
  • Don't give up after the first "no"
Need help with an appeal? Call David at (863) 640-3102. We've fought insurance companies before and won. Happy to help you do the same.

Still Dealing With Denials?

Call David: (863) 640-3102
Email: dhuff@healthmarkets.com

We speak insurance company. We'll help you translate the nonsense and fight back.