The Lesser-Known Trick You Can Use To Dispute High Medical Bills

Medical services are one of the most significant expenses for many Americans, with the average person spending almost $15,000 on healthcare in 2023. When insurance is involved, things get even more complicated as patients contend with the real fear that an unapproved procedure or uncovered medication will lead to additional financial hardship in a time where health insurance premiums are already rising for millions of Americans. While the prospect of combatting an insurance company's ruling may seem intimidating, consumers do have a legal right to appeal decisions made by their insurer. However, less than 1% actually do so, according to KFF.

Through an external appeal, consumers can challenge an insurer's decision if it denies coverage for treatment. To use this option, a patient and their doctor can submit a request through a state-approved Independent Review Organization (IRO) to begin the external appeal process. Afterwards, the IRO assigns independent medical experts who are not affiliated with the insurance company to review the claim and patients' records to evaluate if the denied treatment is medically necessary. Based on the external party's decision, the insurer could be forced to overturn its denial and cover the cost of the procedure.

Before individuals can even request an external review, they must first go through their insurer's internal appeal process. During an internal review, the insurance provider will evaluate whether its initial decision was the right one. Whether you're a senior looking to avoid healthcare costs that sneak up in retirement or a younger patient trying to minimize your spending in general, this first step in the appeals process can be an effective avenue for cutting down on healthcare costs on its own. 

If your internal appeal gets denied, that's when it's time to consider the external review process. However, there are strict requirements to do so. Patients must submit a request within four months of the insurer's final decision, and it must be in writing to a state's IRO. In states that don't offer their own specific external appeal options, residents can contact the Department of Health and Human Services for an external review instead. After requesting an external review, the IRO has 45 days to make a binding decision. The Affordable Care Act also provides expedited external reviews in emergency events. Results may vary, but if you're facing down a substantial medical bill that you believe falls under your insurance coverage, there's no harm in attempting to appeal the claim. In fact, there are individuals who have undergone the external appeal process to great success.