How to fight against denied medical claims and hefty bills
Experian: 73% of healthcare providers are seeing a rise in claims denials
(InvestigateTV) — For many Americans, receiving an unexpected, sky-high medical bill after an insurance claim is denied is an all-too-common nightmare. With medical expenses being one of the leading causes of bankruptcy in the U.S., understanding how to challenge a denied claim is crucial.
Medwise Insurance Advocacy President and CEO Adria Gross has spent 35 years working in the health insurance industry. She knows the ins and outs of the system, including why claims are denied and how families can advocate for themselves.
Step 1: your insurance company
If you receive a bill for services your insurer refuses to cover, the first step is to call them directly.
“The first thing that you need to do is ask the insurance company why they’re not covering you,” Gross said. Understanding their reasoning is key to building a case for your appeal.
Step 2: File an appeal
While the appeals process can seem daunting, Gross reassures that persistence pays off.
“A lot of times, the insurance company will deny your first appeal,” she explained. “But they may allow you to appeal again. This is where your doctor’s becomes essential.”
Gross recommended returning to your physician and requesting a second, more detailed letter explaining the medical necessity of the treatment. A well-documented explanation tailored to the insurance company’s requirements can significantly strengthen your case.
Step 3: Seek state assistance
If your insurer denies your appeal, don’t give up. Each state has agencies dedicated to handling insurance complaints, often housed under departments focusing on banking, consumer affairs, or medical billing.
“They have different titles depending on the state, so research who handles insurance appeals where you live,” Gross said. “And don’t just write to one person—send your appeal to multiple s within the agency. You can use the same basic letter, detailing why the service was necessary and what happened with your claim.”
Navigating the insurance system can be frustrating, but being informed can make all the difference, Gross said. Even if an appeal is unsuccessful, understanding the process equips you to better advocate for yourself in the future.
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