Emergency Room Surprise! How to Fight a Denied Claim After an ER Visit

June 11, 2024

Emergency Room Insurance Claims Are Frequently Denied

ER Visits Can Be Expensive

Nobody wants to go to a hospital emergency room.  Unfortunately, life is unpredictable, and when serious medical needs arise an ER is often the best place for treatment

As a result of the services they provide, including immediacy of care, emergency rooms are often the most expensive places to be treated for illness or injury.

The high cost of emergency room visits is particularly problematic for insurance companies burdened with the costs for their policyholders.  Because of the urgency of necessary treatment, most emergency room patients are only aware of the costs of their care once they receive the hospital bills.  There is often no time for pre-approvals and treatment is provided immediately, as needed.

Because of this, it is not uncommon for those who have visited an emergency room to see their insurance claims denied.  These actions leave policyholders responsible for the full cost of their treatment, a financial hardship that may be life-changing.

If you have received a denial or underpayment notification from your insurance company concerning your emergency room bill, you must recognize that this decision is not necessarily final. You do have the option to file an appeal.  In situations where the costs are significant, this is a wise course of action.

The combination of time and knowledge necessary to file an appeal is considerable. The process can be overwhelming. In many cases, engaging the services of a denied claims attorney is a good decision.  This professional can manage the process on your behalf, allowing you to focus your attention on your recovery.

Why Do Insurance Companies Deny ER Claims?

If you have received a letter from your insurance company disallowing your claim, you may be asking this very same question.  If you have paid your premiums in full and on time, you likely expected your medical costs to be covered, particularly in the case of an emergency.  After all, isn’t your insurance company committed to protecting you?

Sadly, the answer to this question is no. We must never lose sight of the fact that insurance companies are businesses whose primary loyalties lie with their shareholders, not their policyholders.  Every claim paid is an expense that decreases their profitability, and emergency room claims are particularly costly.

That said, when your claim is denied, maximizing profitability is not listed as the reason why.   Quite commonly, insurance companies will question whether the treatment in that facility was necessary: Was it actually an emergency? This question, however, is often unreasonable.  Even in situations where an urgent care visit could have sufficed, those who are ill, injured, and in pain do not have the ability to determine in the moment the severity of their condition.  Taking reasonable care to protect their health and perhaps their life should be an acceptable practice.

Unfortunately, the initial response to an ER claim from many insurance companies is an outright denial.

Your Action Plan: Fighting the Denial

Be Proactive

If you have received a denial from your insurance company for services provided by an emergency room, rest assured you do have recourse. Simply accepting the denial as final will result in your being held financially responsible for the costs incurred, the total of which may be astronomical, so it makes sense to appeal the decision.

As in most cases, a little preparation goes a long way.  Developing an action plan to fight the denial is more than just a good idea — it is a necessity.  Consider the following steps.

• Recognize the reason for the denial: Review the letter from your insurance company carefully.  Some possible reasons for it may include the insurance company’s determination that the visit was unnecessary; the ER was an out-of-network provider; the care you received was not covered under your plan; or the treatment provided is categorized as experimental. If the denial was in bad faith, moving forward with your appeal is a wise decision.
• Gather important information: In order to appropriately submit an appeal, you will need to have access to a number of key documents, including a copy of your policy, the denial letter sent by your carrier, and all of your medical records. If you don’t have this paperwork on hand, take time now to request it.
• Identify the appeals process: Every insurance company has its own process for submitting an appeal for a denied health care claim. In order to have your case reviewed, you must follow their procedures exactly.  Some may request you to submit the appeal electronically, while others may require documents to be mailed to them. Failure to follow these instructions can result in your request being denied outright.
• Draft a letter of appeal: Take time to craft a carefully worded letter of appeal.  You want to be able to reference facts from the documents you have gathered, particularly if you can refute the reasons for the denial.  Requesting an appeal in writing is important; you want to have proof of all communications.  Do not embark upon the appeal process through telephone calls.
• Submit your appeal package: Once your letter is complete, you want to send it, along with all corresponding and referenced documentation to the insurance company in the manner they request.  Be sure to keep a copy of your letter and the attachments.  Additionally, it is in your best interests, if you need to submit a hard copy through the mail, to send these documents certified or express mail, so you have a record of the insurance company’s receipt.

It is important to work on appeals as quickly as possible, as most insurance companies will only accept them within a specific period of time. If you wait too long, you may find you are no longer eligible to question the decisions.

Need More Help? Consult an Insurance Lawyer

You Don’t Have to Handle This Alone

The insurance appeals process can be overwhelming, especially for someone who is dealing with the aftermath of an emergency room visit.  The process can be confusing and incredibly time-consuming. It may be comforting to know that help is available.

For many, engaging an insurance claims attorney provides them with much-needed peace of mind.

They can rest assured that their request for an appeal will be submitted appropriately and in a timely fashion, and that pushback from the insurance company will be dealt with by a professional who understands how to communicate effectively in situations like this.

Quite often, the representation by an attorney is the push insurance companies need to conduct the requested review. Once they realize they are operating on more equal ground, they are less likely to stand by their bad faith actions.

Contact Attorney Doug Terry for Help with Your Emergency Room Insurance Denial

Attorney Doug Terry and his team are often the first calls for those in Oklahoma whose emergency room insurance claims have been denied. He has decades of experience and a reputation for successfully representing his clients and providing them with compassionate and attentive service.

Mr. Terry spent years defending insurance companies before transitioning his focus to supporting policyholders. He leverages this experience on behalf of his clients; he understands the tactics these organizations take and knows how to combat them. Emergency room visits and health insurance denials made in bad faith place undue financial and emotional burdens on policyholders, leaving them frustrated and overwhelmed. He and his team understand and appreciate this and are ready to go to work for them immediately.

If your emergency room insurance claim has been denied, reach out to Doug Terry today to schedule a free consultation.  He can review your situation and share exactly how he can advocate on your behalf.  In all situations, Mr. Terry focuses on the best interests of those he represents, with the goal of maximizing their settlements and minimizing the stress often associated with insurance claim appeals.  Contact him today at 405-463-6362 to learn how he can help you during this challenging time.