Contesting a Denied Insurance Claim

Your insurance company denies one or more of your claims and all of a sudden you are responsible for paying the bill. This scenario is uncommon in other fields of medicine, but can happen all too often in the field reproductive endocrinology. Infertility treatments are often viewed as elective, and as such coverage of such services can vary dramatically from plan to plan. Today I will go into more detail about why this happens and, more importantly, what you can do to contest your insurance company. But before I go into more detail I want to give you some advice: If you are seeking fertility treatment to help you conceive I recommend learning what your benefits are!

Why claims can be denied

As I briefly touched upon above, one of the roots of the problem with insurance coverage for infertility is that every policy seems to have a different degree of coverage. It is fairly common for a policy to have diagnostic coverage, where they will cover services and tests to determine the nature of your infertility, but no coverage for treatment. Treatment can be defined as to any service that is carried out with the goal of getting you pregnant. To further complicate this picture, when an insurance policy does cover infertility treatment, exactly what treatments it covers is unique to that individual policy every time.

To make matters worse, each insurance company can have slightly different definitions of how each service is classified. For large items like an IVF cycle or IUI cycle, there is usually very little uncertainty. However, for smaller things like certain diagnostic tests, the answer of coverage can be unclear. To make matters worse, the insurance company cannot/will not always tell the clinic if something is covered or not. So even if you ask your clinic, and they talk to your insurance company for you, they might not be able to obtain a clear answer. Very frustrating for both the clinic and the patient. If you have ever spent some time on the phone with your insurance company, you will know what I am talking about.

Okay, so you may be thinking that the whole thing sounds terribly vague and disheartening. Despair not! If you happen to find a charge on your bill or on your Explanations of Benefits (EOB) that you think was denied incorrectly you can contest it.

Contesting a denied claim

As the patient, you have the power to contest any denied charges with your insurance company. That being said, you should only contest claims that you believe were processed incorrectly. Example: If you know you don’t have coverage for IVF and your insurance denies the claim, it is a waste of time to try and contest it. If you have something that you believe should be covered under your particular insurance benefit.

Rule #1 (my only rule here actually): Document everything! Take notes on who you talk to, their extensions, or how you can talk to them again, and any pertinent details of the conversation. This can save you tons of time!

First thing you should do is talk to your insurance company. Call the customer service number to get the details of why the charge was denied. The more details you can gather the better, and write down the name and extension of the person who helped you. Find out exactly why the service was denied. Was it because it was classified under an ineligible benefit, hopefully due to a billing error at your clinic? Was the service not deemed medically necessary? Depending on their answer you will have different courses of action.

If you think the denied service was billed incorrectly, call the clinic to make sure they billed it correctly. It is uncommon, but sometimes this can be the result of an incorrectly entered CPT(procedure) or ICD(diagnosis, or DX) code on their end and just having them correct the error and resubmitting the service can solve the whole thing.

If the service was denied due to not being “medically necessary” (common for uterine polyp removals) the course of action is to escalate the issue with your insurance company. They will ask your doctor for chart notes and sometimes a letter explaining why they think the procedure was necessary. The insurance company usually does the following up in this case, so your work is done for now.

My last advice to you is to make sure you follow up on your case! Medical offices, and especially fertility clinics, can be very busy and sometimes it takes a gentle push to get things done. However, make sure you are polite in any of your inquiries, and don’t call everyday! The office usually wants to help you, and often just need a reminder or two. Getting angry, or otherwise unpleasant with any of the staff will get you nothing.

If you have any stories of denied claims you were able to successfully (or unsuccessfully) fight please share them below. As always comments and questions are welcome!

Cheers!