Health Insurance Denials

Denials are not uncommon in NETs. Financial toxicity is a real fear when an insurance company refuses or denies coverage of a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional. In this instance, your insurance contract will stipulate what you need to do to appeal that decision. You must follow up on all denials to learn exactly what the issue or situation was that caused it. Here are some common scenarios—

• Wrong code: A billing office may have entered the wrong diagnostic or treatment code. You can find this out by a phone call to your insurance company or you may see it noted on your Explanation of Benefits (EOB) statement. Sometimes a simple re-filing of the claim with the correct diagnostic code is all that is needed.
• Not medically necessary: When a test or treatment is deemed not medically necessary you or your doctor will need to appeal. Keep in mind your insurance is a business contract, and you need to understand what that contract or policy covers, what your rights are, and how the appeals process works. Keep your complete statement of coverage on hand and request one if you cannot locate it.
• Experimental: Sometimes when a treatment or diagnostic tool is approved by the FDA, it takes time for insurance companies to catch up; often the private carriers wait for Medicare to approve before they will consider it established. This denial will likely require the help of your doctor or even further steps to prove it’s no longer experimental (or in clinical trial).