Medical Insurance Claims: Disputes, Denials, and Your Options

Medical Claims Are Different From Property Claims

Medical insurance claims — disputes with your health insurer over denied procedures, coverage determinations, or billing issues — are fundamentally different from the property and casualty claims that a Public Adjuster handles. Health insurance is regulated under a separate set of laws and involves different dispute resolution processes. While a Public Adjuster specializes in property damage claims (homeowners, commercial, auto physical damage), medical claim disputes require professionals with expertise in health insurance regulations and healthcare law.

Common Medical Insurance Disputes

• Denied claims and procedures: Your insurer refuses to pay for a procedure, treatment, or medication that your doctor has recommended, often citing medical necessity or policy exclusions.
• Prior authorization disputes: The insurer denies or delays authorization for a procedure, test, or specialist referral that your doctor has ordered.
• Out-of-network billing:You receive a bill for out-of-network charges that you did not expect, often from an anesthesiologist, radiologist, or other specialist who was not in your plan's network even though the facility was.
• Balance billing (surprise billing): A provider bills you for the difference between their charges and what your insurer paid. California and federal law provide protections against many forms of surprise billing.
• Coordination of benefits: Disputes when you have coverage under two or more health plans about which plan pays first and how much each plan covers.
• Claim processing errors: Incorrect coding, missing information, or administrative errors that result in a claim being denied or underpaid.

Your Rights in California

California provides strong protections for health insurance consumers. If your claim is denied, you have the right to an internal appeal through your insurance company and, if that is unsuccessful, an independent medical review (IMR) through the California Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI), depending on your plan type. The IMR process is free and the decision is binding on the insurer.

Who Can Help With Medical Claims?

Depending on the nature of your dispute, several types of professionals may be able to help:

• Patient advocates: Professionals who specialize in navigating the health insurance system, helping with appeals, resolving billing disputes, and communicating with insurers on your behalf.
• Medical billing advocates: Specialists who review medical bills for errors, negotiate with providers and insurers, and help reduce your out-of-pocket costs.
• Health insurance attorneys: Lawyers who specialize in health insurance law and can represent you in disputes involving significant amounts, bad faith denials, or ERISA (Employee Retirement Income Security Act) plan disputes.
• State regulators: The California DMHC and CDI both accept complaints and can intervene in disputes between consumers and their health insurers.

How We Can Help

While medical insurance claims are outside the scope of what a Public Adjuster handles, Leland Coontz III can help point you in the right direction. If you are dealing with a health insurance dispute, reach out and we will do our best to connect you with a patient advocate, medical billing specialist, or attorney who can assist with your specific situation.