Don’t rush to pay out of pocket if your health insurance denies a test, treatment, or medication your doctor says you need.
Consumer Reports says you have a guaranteed right to appeal that decision—and the good news is, it’s easier than you might think.
In 2023, nearly 1 in 5 in-network health insurance claims from plans sold on Healthcare.gov were denied, and it was even worse for out-of-network claims, with more than a third turned down.
But denial doesn’t mean you should immediately pay out of pocket, or skip the care you need.
Consumer Reports says it’s easier to appeal a denial than you might think.
First, call your insurance company because sometimes, it’s a simple billing mistake or paperwork error that is only standing in your way. Mistakes can and do happen at multiple points in the claim-filing or pre-authorization process, and once you identify them, they are often relatively easy to fix.
If it was not a mistake, you have the right to appeal. Ask to speak directly to the reviewer who made the decision and get a clear explanation for why your claim was denied.
You’ll need this information for the next step: filing a formal appeal stating that you disagree with the decision.
Ask your doctor to help write a letter explaining the procedure’s necessity, and include as many supporting documents as possible, like your medical records, treatment studies, and any communication with the insurance company.
Doctors are used to this, so don’t be afraid to ask.
The next step might be the hardest: waiting! An answer could take 30 days or more.
If you need treatment right away, make sure you request an expedited review.
And, if you get a letter that the insurer is STILL choosing to deny the claim, both Medicare and the private insurance are required by law to give you the reason in writing and tell you how to appeal the decision for review by an independent third party.
If you get your insurance through work, consider asking your human resources department for help.
If Medicare denied your claim, consider getting legal help to hear your case before a judge.
There’s a law that’s supposed to protect you from surprise medical bills, but if you still get one, Consumer Reports says one of the best things you can do is ask for an itemized bill and question every charge before you pay.