A short thread on how to get a health insurance claim denial reversed (UPDATED AGAIN!!)
Originally found on Bluesky here, I am reposting here on Tumblr hoping that this gains some traction coz I know a LOT of folks who could benefit from it here in the US healthcare system.
Please, please, please reblog this and TAG it (if you have additional ideas for tags, go for it).
UPDATE: And then ProPublica added a godsdamned FORM you can use!
You likely have the right to access records that explain why your insurer denied your claim or prior authorization request. Use ProPublica’s
UPDATED AGAIN!!
For those of you who are doing the dance of Prior Authorizations -- in the event that your PA is denied, *CALL THEM* and ask specifically WHAT INFORMATION WAS MISSING to cause the denial. DON'T ask "Why was it denied?", ask, "What information was missing?"
When I called to ask why my doctor's submission was denied, I didn't get a straight answer. I called back and asked, "What information was missing that my doctor should have provided for this to be approved?" The rep looked over the form my doctor had submitted and said, "She said you didn't have a sleep study done, and a sleep study showing an OSA diagnosis and 15+ events is required."
Now I DID in fact have a sleep study done, and I had the CPAP prescription (with that exact diagnosis and info on it) to prove it.
So I asked the rep, "If my doctor resubmits the form and confirms that I DID have said study done and DID have said diagnosis and so on, would that get my PA approved?"
"Yep!"
I IMMEDIATELY called my doctor's office to tell her, and sent her the PDF of my CPAP prescription with additional deets. She in turn immediately resubmitted the corrected form, and a couple hours later, VOILA, PA approved.
So be sure to phrase your question CORRECTLY, because IF THEY TELL YOU WHAT YOUR DOCTOR NEEDS TO SAY, THEY'LL ALMOST CERTAINLY APPROVE IT.
Putting Patients and Physicians in an Unnavigable Maze
Miranda Yaver for Can We Still Govern?:
As news erupted across the country on December 4, 2024 that the UnitedHealthcare C.E.O. was killed in New York City, alongside rightful condemnations of violence was an outpouring of frustration with delays and denials of coverage, predominantly at the hands of private health insurers.
To casual observers of the American health care system, it might seem puzzling that in the world’s wealthiest nation, there would be such widespread grievances about barriers to prescribed medical care. But to many Americans – especially those with chronic medical challenges – this only scratched the surface of health care burdens and the intensely political processes driving these barriers.
Every day across America, people learn that they cannot pick up prescribed medication or schedule a test or procedure because their insurer has not provided prior authorization, or required pre-approval for prescribed care.
In prior authorization’s nascency in the 1960s, it was quite narrowly circumscribed, such as requiring physicians to certify the necessity of a continued hospitalization. As health care inflation and soaring Medicare costs intensified cost containment pressures, America expanded its reliance on managed care. With it came new incentives: coverage decisions were made not simply by prescribing physicians (who in fee-for-service arrangements had some degree of perverse incentives to overprescribe), but by entities with fiduciary responsibilities to shareholders and obligations to contain costs and maximize profits.
Utilization guardrails proliferated, ostensibly to mitigate waste. What began as certification of hospital lengths of stay expanded to prior authorization for costly drugs (and even some less costly ones), high-tech imaging, and many surgeries and procedures. What may have begun as an effort to curb overprescribing has resulted in the delay and denial of medically necessary care, along with the imposition of burdensome processes to reverse them. That is the story I tell in my new book, Coverage Denied: How Health Insurers Drive Inequality in the United States, drawing on interviews, a nationwide survey, and administrative data.
The Prevalence of Coverage Denials
Because health insurance is fragmented across public and private payers, precise denial rates are difficult to determine and consequently, most analyses focus on slices of the market. For example, KFF finds that roughly 1 in 5 claims are denied each year by Affordable Care Act marketplace plans, though KFF’s analysis of prior authorization denials by Medicare Advantage plans revealed a lower denial rate of just under 8 percent. And Optum found through analysis of hundreds of millions of claims that the denial rate has increased from 9 percent in 2016 to 12 percent in 2023.
Surveying 1,340 patients nationwide, I found that 36 percent of survey respondents experienced at least one, typically more than one, coverage denial. These denials were for wide-ranging care, from prescription drugs to behavioral health to imaging to surgeries, highlighting the breadth of this practice in modern health care delivery.
Denials can occur pre-treatment (through denial of prior authorization) or post-treatment (a claim denial). Both are destabilizing for the patient and burdensome to rectify, but their effects are felt quite differently: prior authorization can keep care out of reach, while claim denials can jeopardize financial security and drive medical debt. While I do not observe pronounced disparities in susceptibility to being denied in the first place, the administrative and financial burdens of denial fall inequitably, with patients from marginalized backgrounds bearing the brunt of this managed care tool.
For the love of everything that's fucking holy if you have a surgical procedure in January get them your 2026 insurance info!!!!
I'm getting tired of chasing people to prevent them from getting denials from THEIR insurance company!! Drives me crazy I have to call, text, myChart message ppl and still get no response. How do you emphasize how important this shit is to people who don't care!?!?!
X93.XXXA is not on UnitedHealthcare's Prior authorization List, and is not covered. Have you tried any conservative therapy such as Phycian directed home therapy, OTC meds and/or physical therapy? You can also just file an appeal with-
