Why do insurance companies deny health insurance claims?

It can be incredibly frustrating to get a Massachusetts doctor’s bill and see your insurance company denied a service. You may wonder how they can do that if your doctor thought something was needed. It can be upsetting. Plus, it leaves you holding the responsibility to pay the bill. It can almost make you question why you even have insurance. Is it legal for insurance companies to deny your claims?

The answer to that is yes it is. These companies do not have to approve every claim you send their way as long as they abide by the agreement you signed when you got the insurance. According to VeryWell Health, many times a denial is due to a claim for services, medications or other things that are not covered under your insurance policy. The services from a specific provider may also not be covered and lead to a denial.

Along those same lines, some denials are due to not following the proper procedure. For example, pre-authorization is common for many services. If you fail to get pre-authorization, your insurance company does not have to pay the claim.

Other reasons that a claim may not go through include paperwork errors or a lack of information. It is essential to check with your provider’s office to make sure they sent everything and that all information was correct.

Your insurer may also feel the provider should have tried an alternative and therefore refuse to pay. Many companies want providers to try cheaper treatments or solutions first and will deny claims for more expensive options unless the alternatives are tried prior. In some cases, an insurance company may even feel the service is not medically necessary and will not cover it. This information is for education and is not legal advice.

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