How To Handle Health Insurance Denials When Living With Chronic Illness
Dealing with health insurance denials is one of the most frustrating hurdles for anyone managing a chronic illness.
Unfortunately, it will happen to most of us at some point. It can feel unfair, overwhelming, and emotionally draining to fight for the care you need when you're already navigating the complexities of symptoms, treatments, and daily life.
But, it is important to note that a denial is frequently not the end of the road for your insurance claim. It usually is just the beginning of a process where the insurance company needs more information to determine an expense as “medically necessary.”
With persistence, organization, and the right strategies, you can often overturn insurance decisions.
This post will walk you through the steps to help you advocate for yourself and feel more empowered in the process.
Please note that this blog post is not intended as legal advice. As mentioned below, if you need assistance, please consult your healthcare provider, insurance company, patient advocate or legal counsel for advice tailored to your specific circumstances.
With that disclaimer in mind, let’s get to it.
Tips For Handling A Health Insurance Denial
Understand your insurance coverage
The key to tackling any insurance issue is understanding your policy. While this may sound obvious, decoding your insurance plan can be surprisingly tricky. Start by reviewing the relevant documents like your summary of benefits or your explanation of benefits. These outline which services are covered, how much you’ll pay out-of-pocket, and limitations like required prior authorizations.
Action steps to gain clarity on your coverage:
Identify your plan’s in-network providers to avoid surprise expenses from seeing an out-of-network provider.
Check medical services covered under your health benefits.
Note any specific exclusions that can impact what is covered.
Knowing the details of your coverage gives you a solid foundation to push back against denials, and might help you avoid some insurance pitfalls.
Stay in-network whenever possible
Using in-network providers is often a non-negotiable requirement for coverage, depending on the type of plan that you have. If you visit out-of-network providers, your insurance may deny the claim entirely or offer much-reduced reimbursement. Always verify a provider’s network status before scheduling services or treatments—especially if you're referred to a specialist.
Pro tip:
Call your insurer to confirm network compatibility, even if a provider’s website claims to accept your insurance.
Double-check this information yearly, as provider contracts with insurers can change.
Keep Your Documents organized
Documentation is your strongest ally when challenging a denial. From medical bills to insurance correspondence, keep a meticulous record of anything related to your claim. A detailed and organized record can make all the difference when initiating an appeal or presenting your case to your insurer.
Use a folder (physical or digital) to store all documents, including:
Insurance statements
Medical bills
Doctor’s notes or treatment plans
Letters explaining denials
Logs of phone calls (include date, name of the representative, and details discussed)
secure prior authorizations
Many treatments, tests, and medications require prior authorization from your insurer before coverage is approved. Without this step, claims are often denied automatically. This process can feel burdensome, but think of it as preemptive self-advocacy—it’s your chance to ensure treatment is approved before it even begins.
Oftentimes healthcare providers initiate the prior authorization process without needing your involvement. Your healthcare provider has an interest in being paid for their services. Therefore, most are not likely to leave this to chance. Larger providers, like hospital systems, frequently utilize their staff to handle prior authorizations on your behalf.
How to prevent surprises:
Determine if the prescribed treatment needs prior authorization.
Follow up directly with your insurer to confirm they have received and approved the request.
Keep copies of all communication regarding the authorization.
Work with your healthcare team
Your healthcare providers can be valuable allies when dealing with insurance denials. At many larger healthcare providers, the staff initiate most of these processes for you. They are often willing to support appeals by providing documentation that justifies medical necessity. Their professional expertise carries substantial weight in addressing contested claims.
For example, I was recently ordered a stress echocardiogram to monitor cardiovascular damage from past cancer treatments. My insurer denied the prior authorization request because I was not experiencing chest pain. When I let my healthcare provider know about the denial, they were able to contact my insurer and set up a time to discuss why it is the standard of care for someone in my situation to receive this test every few years - with or without chest pain. While I needed to reschedule the test due to this delay in the process, I was able to get my stress echo covered.
Ways your doctor can help:
Submit detailed medical records or letters explaining why a specific treatment is essential.
Propose alternative treatments that might align with your insurer’s policies.
Communicate directly with insurance representatives, if necessary.
Your provider’s willingness to advocate for you can play a huge role in resolving insurance issues.
appeal the denial
If your insurance claim is denied, don’t take it at face value. Insurers often rely on generic processes that don’t always align with complex medical conditions. Appealing a claim might take time and effort, but many initial denials are ultimately overturned.
Steps to file an appeal:
Request the reason for denial in writing if you have not received it. Insurers are legally required to provide this information.
Review your policy and gather evidence to support your case. Work with your healthcare provider to do this.
Prepare your appeal, including detailed explanations, medical records, and any supporting letters from your doctor. Your healthcare provider can assist with this.
Submit by the deadline specified in the denial notice. Missing this date could forfeit your chances of overturning the decision.
Track your appeal’s progress, and don’t hesitate to follow up.
Many insurance companies have multiple levels of appeal—don’t stop after the first rejection.
seek professional help when needed
Sometimes, navigating insurance denials feels too complicated to handle alone, especially when chronic illness limits your energy and focus. If you’re feeling stuck or overwhelmed, consider enlisting professional help.
Resources to consider:
Patient Advocates: These professionals specialize in resolving insurance disputes and can provide invaluable support.
Case Managers or Social Workers: Often affiliated with hospitals or healthcare providers, they can guide you through the appeals process.
Legal Assistance: If your appeals are unsuccessful, legal intervention might be an option, especially if your insurer may have violated state laws.
While seeking help may add an initial cost, it can save you time, energy, and even money in the long run.
Need More Self-Advocacy Tips?
Find them in my upcoming Chronically Well offerings and read THIS blog post about 3 steps to advocate for yourself in the healthcare system.
Remember, a initial denial is not the end.
It’s easy to feel defeated when faced with a denial, but it’s important to hold onto hope. Insurance companies often deny claims. Don’t give up because you don’t want to deal with it. I am urging you to advocate for what you need in the healthcare system with the support of your healthcare providers.
Persistence, organization, and advocacy can turn the tide in your favor.
Think of every step as an opportunity to build your case and empower your voice. Whether it’s organizing your documents, leveraging your healthcare provider’s support, or pursuing an appeal with confidence, you have the tools to push back.
What steps can you take to advocate for yourself when dealing with a health insurance denial?
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