You can ask that your insurance company
reconsider its decision. Insurers have to tell you why they’ve denied your claim or ended your
coverage. And they have to let you know how you can dispute their decisions.
It's unsettling to receive a
letter from your insurance company telling you that your request for medical
care, or for payment of care you've already received, has been denied. But
there are some steps you can take to help boost the odds of filing a successful
appeal.
Martin Rosen, a co-founder of
Health Advocate, a business that
helps people who get their insurance through their employer navigate dealings
with their insurance company, says the key to avoiding a denial in the first
place is knowing the details of your insurance policy before you seek
treatment. (The company also offers advocacy services, for a fee, through
Health Proponent, for those who buy insurance on their own.) But if you do
receive a letter denying coverage, and you and your doctor believe you have a
strong case to fight the denial, Mr. Rosen offers these tips:
- Check the details
of your insurer's appeals process. In the coverage documents and
summary of benefits, insurance companies are required to give all the tools
needed to properly make an appeal. There are often deadlines to meet, so act
quickly.
- Have your paperwork in order. Keep records of everything: the
bills from your provider, your explanation of benefits, copies of denial
letters, medical records, letters from your provider of care, etc.
- Call your human resources department if you receive coverage
through your employer. The department may provide direction, advocate on your
behalf and help to translate the fine print of the policy.
- Enlist the help of your doctor. Check the medical policy and
ask your doctor to review it to prepare something called a letter of medical
necessity to support your case.
- Take detailed notes when you speak to the insurance company.
Write down the time and date, length of the call, the name and title of the
person you speak with and all the details of the conversation. Make note of any
follow-up activities and next steps by all parties.
- Write down your argument. Make notes of exactly what happened,
when and why. If you are seeking approval for treatment, note any supporting
science, clinical evidence, expected benefits, etc. Be clear, firm and concise.
Make it clear that you plan to pursue the appeal until it is resolved, the
claim is paid or care is approved.
- Follow up with your insurance company. Many appeals take
weeks, even months, so call often to check the status and take notes of each
call.
Most insurance companies have
at least a three-level appeals process. Appeals at the first level are usually
processed by the company's appeals staff or by the company's medical director
responsible for the denial. Second-level appeals are reviewed by a medical
director not involved in the original claim decision. And the third level
usually involves an independent, third-party reviewer, along with a doctor who
is board-certified in the same specialty as the patient's doctor.
If your appeal is elevated to
the third level and the insurance company continues to deny the claim, you can
then take the appeal to the state level. Processes vary by state; you can
contact your state's insurance department for details.
If you feel too frail or
overwhelmed to pursue an appeal yourself, nonprofit groups like the
Patient Advocate Foundation can provide guidance for free. Fee-based
services like Health Proponent are also an option. The service has been
experimenting with different fee structures and is joining with affinity
groups, like alumni associations and the American Automobile Association, to
broaden its membership.
Health Proponent charges
$29.95 a year for individuals and their families to join and charges additional
fees, depending on the type of service it provides. If you have a claim denied,
for instance, it will research the problem for a flat fee of $99. (That means
using the service for claims of less than that amount doesn't make sense.)
If you have uncovered medical
bills totaling at least $400, the company will attempt to negotiate a reduced
bill (there's no upfront charge for the service, beyond the annual membership
fee).
The service previously charged an hourly rate for this service, Mr. Rosen
said, but has switched to a percentage fee. If the company can't negotiate any
savings, you pay nothing to Health Proponent; if it does get the bill reduced,
you pay 25 percent of the savings as a fee. (Say you are billed $10,000 which
is not covered by your insurance, and the company negotiates the amount down to
$5,000 - half the total. You pay $5,000 to the provider, plus a fee of $1,250
to Health Proponent. So you pay a total of $6,250, a savings of about 38
percent.)
Have you appealed a denied
health insurance claim, with or without paid assistance? What was the outcome?
Your right to appeal a denied claim was expanded under the
Affordable
Care Act. Now your insurance company is required to tell you why your claim was denied, and you
have up to six months to appeal." MORE:
5 reasons your health insurance plan will deny your medical claim
You can maximize the chances that your appeal will be successful by following these tips.
1. Understand why your claim was denied
Before you can fight a denied claim, you need to understand why it was denied. Your explanation
of benefits (EOB),
a standard form sent by the insurance company whenever your claim is approved or denied, uses codes
to explain how the company arrived at its decision. Most EOBs will also provide a key to the codes,
so you can find out what they mean. If you still aren't sure why the claim was denied, call the company
and ask. You have a right to this information, and the insurer has a responsibility to explain it
in terms you can understand.
2. Eliminate easy problems first
Sometimes your claim was denied only because of a data-entry error like a misspelled name, insurance
ID number, or the wrong date of service. Read through all the documentation from your insurance company
carefully and look for errors. If you find one, ask the insurance company to correct it before you
proceed. If it was an error on the part of your medical provider, ask her to correct the problem
and resubmit the claim.
3. Gather your evidence
Make sure you have all the evidence to show that the services you want covered are medically necessary.
Referrals, prescriptions from your doctor and any relevant information about your medical history
may help your claim get approved the second time around. You or your doctor will also want to reference
your health plan's medical policy bulletin or guideline for the treatment you received. These are
often available online through your health plan's website.
4. Submit the right paperwork
You may need to write a letter to your insurance company. If you do, make sure to include your
claim number and the number on your health insurance card. But your claim may be processed faster
if you use the insurance company's standard appeals form. The explanation of benefits you received
should tell you how to appeal the decision, or you can call your insurance company directly and find
out how to appeal.
5. Stay organized
The insurance company has its own internal system for tracking your medical claim and any subsequent
appeals. You have to be just as organized to make sure you're following up on any detail that may
make the difference. Keep all your paperwork in one place and take careful notes during every phone
call with the insurance company. Ask for the name and the job title of the person you're speaking
to and write down the date of the conversation and any next steps. You should also ask for what's
termed a "call reference number," and if an appeal was submitted, get the "document image number."
This information will help you build your case and ensure that the next customer service agent you
speak to can quickly access all the necessary files to help you move the appeal process forward.
6. Pay attention to the timeline
It's easy to call the insurance company once and then forget about it, but you have to follow
up. Set up a system to remind yourself to follow through. If a customer service agent tells you he
is going to resubmit your claim and it will take about a week to be processed, make a note in your
calendar to call back in a week to check on the status. The company is more likely to move your claim
through the pipeline if you apply a little gentle pressure.
7. Don't shoot the messenger
Having a claim denied is scary. If you're waiting for pre-approval before you can have tests or
a necessary procedure, it can be even worse. But don't forget that the person on the other end of
the phone is probably not the person responsible for denying your claim. She might be a valuable
ally, so treat her with courtesy and respect. If you find yourself getting upset, explain that you're
very concerned about your case but you know it's not her fault.
8. Take it to the next level
Until now, you've been appealing the decision directly with your insurance company. But if your
claim is denied a second time, you may have one more chance to change their minds. The Affordable
care Act requires that states set up an
external review process for denied medical claims. Check the
Centers
for Medicare and Medicaid Services site to see whether your state has implemented the new guidelines
yet.
9. Speed things up
If you need medical care urgently, you may not be able to wait for the company's internal appeals
process to run its course. "You can file an expedited appeal if the timeline for the standard appeal
process would seriously jeopardize your life or your ability to regain maximum function," says
Healthcare.gov. In such cases, file internal and external appeals simultaneously. If you're too
sick to take care of this on your own, your doctor can file an external appeal on your behalf.
MJ Columbus OH
July 12, 2011
Unfortunately sometimes the only way to get around denial of precertification is to ask your doctor
to lie. I had an MRI after a fainting episode that showed possible MS, which runs in my family. All
other diseases were excluded. The medical recommendation is to get a follow-up MRI in 6-months. Because
I wasn't having active symptoms, the follow-up MRI was not pre-certified when ordered by my neurologist.
I went to my family physician for help, she requested the MRI, saying I was having headaches (everybody
gets one occasionally, right?). I immediately got the necessary MRI and am now being treated. I think
the insurance company didn't really want to deny the MRI, they wanted to delay expensive treatment,
which was the likely outcome.
o'keefe illinois
July 12, 2011
I am currently appealing a claim with HealthLink. Too long to go into but it involves an Intensive
Outpatient Treatement program for my 20 year old son. There own guidelines state that this may well
be the best initial choice for treatment. However, they advised us when they would not pre-certify
that he needs to fail at out patient treatment and community support. Really? So I get to the External
appeal process.
Healthlink contracts with MCMC to provide the physician to do the review. Can we
say conflict of interest? She spits out the same verbage used to deny the precertification but mentions
criteria that is no longer being used to asses such cases. Or and then there is the mention of my
son's "wearable cardioverter defibrillor" has nothing to do with our case. So I appeal to the State
of Illinois (eye roll) and am told I cannot appeal a denial of a precertification. I must have a
denied claim. OK, but I can't get to the denied claim as HealthLInk won't even percert the care.
Who are these people?
Clint N. NYC
July 12, 2011
I recently had to deal with the insurance company VS primary care provider VS patient VS lab test
provider. Its a cluster-expletive. Even trying to keep track of who said what when is difficult.
Not too mention the hours upon hours of your precious time it *will* consume.
Short summary:
I had a severe flu (possibly swine flu) and made a doctor's appointment. They were very busy and
couldn't see me for 2 weeks. When I came in for my appointment, I had recovered from the flu. My
appointment was reclassified as well-care. My job's health insurance plan was revised two months
prior to exclude well-care. I was now on the hook for 100% of the cost of the visit. The doctor ordered
a full blood work since I was a new patient.
I realize it was my fault that I didn't know well-care wasn't covered. Lesson learned - I've read
my EOB a couple times now, cover to cover. Unfortunately, I still only kind of know what is covered.
Anne Marie Bryn Mawr, Pa.
July 12, 2011
As a practicing physician who is fed up with the way insurance carriers have managed to take over
the delivery of health care in this country, my comments, I warn you, will be brutally frank. The
way the game is played, the providers of health care bill as much as they believe they can get away
with. That's because they are in business to make money - that's why it's called "for profit" health
care.
The insurance carriers try their damn best to find excuses to not pay as many of these charges
as they can. Same reason.
These two conspirators become co-conspirators when they play the game of
"crap runs down hill". That's when they come up with things like "co-pays", "deductibles", "co-insurance",
and a whole host of creative ways of attempting to coerce the patient to pick up the tab. So here's
my advice. Don't pay any "balance billing" no matter what they choose to call it.
Activate the pump
that sends the crap back uphill. Write letters to the provider asking for specifics as to the balance
billing. Don't accept their response. Write again.
Write to the insurance carrier and appeal. Then
write the provider with the appeal number from the insurance company. Keep it going round and round.
If contacted by a collection agency, write back explaining your appeals and that your financial condition
won't allow you to pay without getting a disposition from your claim, and a better explanation from
the provider as to why the procedure wasn't covered. Tell them to not contact you again. Tell them
that you refuse to pay until you get a decent explanation. Dare them to sue you. CC a law firm on
all correspondence. Make the providers get hurt enough to fight against the carrier. Bust up their
friendship. Neither will hire a lawyer to get you. The publicity is the only thing they are afraid
of.
KR NYC
July 11, 2011
I am in the process of filing a claim for the first time ever. Cigna denied coverage for an operation
after the fact. This was not even a marginal case, it was an obvious medical need.
I suspect that
insurance companies simply play the odds, deny and spread the costs to hospitals, surgeons, patients
and maybe themselves.
A lot less than paying the whole thing. This has nothing to do with medicine,
as I have discovered. It is about how to boost revenues and damn fairness and the patient. Plan to
fight and publicize my fight. This is as clean cut a case that can be found.
Walter San Diego, CA
July 11, 2011
Having handled over 4000 health care appeals over the past 15 years, this article is a pretty
good basic overview (so long as most of the Comments are ignored). The Affordable Care Act may ultimately
be helpful in making this hodgepodge of rules more uniform, but that remains to be seen.
The ultimate
message for patients must remain clear: It is imperative to FIGHT for the care you need using all
available resources and expertise at your disposal!
Mollace Toledo, Ohio
July 11, 2011
"If you feel too frail or overwhelmed to pursue an appeal yourself, nonprofit groups like the
Patient Advocate Foundation can provide guidance for free."
A single person battling a life-threatening illness or condition is, of course, going to be overwhelmed
and frail. Insurance companies bank on it. My suggestion is to start with advocacy first.
Insurance
companies make things difficult because they are in the business of making money, not helping patients.
They want you to give up. When you have another person or two in your corner everything moves along
better. Especially when the advocate knows how to fight hard and isn't afraid to speak frankly. There
are witnesses to what is happening and you are taken more seriously.
It is ironic that there is now Health Proponent, a company that will fleece you in order to "advocate"
for you. Only in America, folks.
Susan is a trusted commenter Eastern WA
July 11, 2011
I had to have all my teeth extracted before I could begin treatment for throat cancer. I did not
have enough dental insurance, and the oral surgeon's office told me that medical had informed them
it would not pay the remainder.
I contacted mymedical insurance company, which recommended that I wait for a denial and then appeal.
I pointed out that by that time I would be quite sick from the radiation, and would like to deal
with it while I was still capable. Turns out there is a board that considers these things, so I had
both of the oral surgeons, my oncologist, and my ENT all write letters to this board. The medical
insurance company paid for the whole thing, since it was proven to be a medical necessity.
Now, if we could just get the oral surgery place to refund all that we paid, plus the dental insurance,
so that the dental insurance can in turn use my benefit to help repay us for the dentures . . .
Robert Leff Cambridge, MA
July 11, 2011
I have a friend who broke his back in a car accident and as a result has had ongoing medical issues.
He told me that he treats the denials as a game. You submit the entire claim, they reject part of
it, you resubmit the rejected part, they pay part and reject part, and you keep on going until you
get your money.
It seems cruel, but an insurance company's profit is the amount of money each year
that they do not pay out in claims, so the incentive to deny is very strong.
Caught in the Middle Tenafly, NJ
July 11, 2011
After some back and forth, Medicare paid its share of a claim that I, rather than my doctor, submitted,
I then submitted the claim to my secondary insurer who, after further back and forth, said that it
could not pay the claim because it had been agent for my former employer and no longer had access
to the employer's funds.
The employer in turn, after more back and forth, says it plans to submit
this and other claims to the current secondary employer for payment rather than pay them directl
y. The process seems to go on forever.
Barry New Jersey
July 11, 2011
Appealing a health insurance denial which involves a substantial financial liability can be viewed
like any other do-it-yourself endeavor. If you are comfortable handling a matter upon which, say,
$75,000 or more is at stake (which is not uncommon), good luck.
On the other hand, if the stakes
are high, you may want consider having it handled by an attorney who specializes in this area of
practice
TB is a trusted commenter Philadelphia
July 11, 2011
As someone who went through this process recently, I would make the following suggestions:
1) Be very legalistic in your approach to the appeal, and quote appropriately from the policy and
from law (this of course assumes you have a solid legal basis for your appeal).
2) Inform the insurance company in writing that if they require a full appeal, you will hire legal
counsel to research and document your appeal.
3) Remind the insurance company that under ERISA, if you ultimately win, you are entitled to reimbursement
of your legal fees and expenses.
This won't win obviously if you are on shaky legal ground. But if the insurance company is on
shaky ground and just trying to avoid paying a claim (which was the case with us), this sort of saber
rattling can help resolve the question quickly before you end up in a formal appeal. The insurance
company doesn't want you to hire a lawyer if you have a good chance of winning.
I live in the communist state of New York and think it has much to recommend it, despite the high
taxes.
First, we have some rent regulated apartments in New York. Despite the fact that free marketeers
howl, it does serve to preserve a small amount of social diversity (and even though rents overall
arguable might be cheaper, the regulated apartments are a historical artifact and do not affect new
development, which has been considerable).
Second, if you have a health insurance plan with a New York insurer, you have the right to external
appeal (as in you write a letter to the state insurance bureau, they send it off to a doctor
with relevant expertise to determine whether the insurer is in fact within its rights to deny the
claim. I have used this more than once, including times when the insurer tried denying coverage MANDATED
by state law.
And if I had had no right of external appeal, my only recourse would have been to sue them (and
lawsuits in general are uneconomical unless you have, say, $150,000 or more at issue. I have found
the external appeals guys have very little patience with health insurer BS, which is refreshing).
Softpanorama Recommended
...
How to appeal an
insurance company decision HealthCare.gov
Tips for Appealing a Denied Health Insurance Claim - NerdWallet
www.patientadvocate.org/requests/publications/Guide-Appeals-Process.pdf
internally through your
insurance company as well as your rights to an
external ... in
appealing decisions made by a health
insurance company. Patients should ...
guides.wsj.com/health/health-costs/how-to-appeal-a-health-insurance-denial/
But if you choose to
appeal a coverage denial, there are several
strategies that ... First, find out what led to the
insurer's decision, and keep a careful paper
trail.
www.npr.org/sections/.../patients-often-win-if-they-appeal-a-denied-health-claim
Apr 14, 2014 -
Obamacare set national rules for
appealing a denied health claim - a ... to
appeal that
decision to the
insurance company and, if necessary, ...
www.hhs.gov › Health Care ›
About The Law › Cancellations & Appeals
Under the Affordable Care Act, you
have the right to
appeal a health
insurance company's decision to deny payment
for a claim or to terminate your health ...
obamacarefacts.com/appeal-health-insurance-denial/
Under ObamaCare's expanded
appeal rights it's easier than ever to
appeal a health
insurance company denial, a Marketplace
decision, or a SHOP
decision.
www.carinsurancecomparison.com › FAQ
It is often necessary to
appeal a car
insurance company decision when the amount of
compensation offered does not match your idea of the
claim's worth. The.
https://www.insurance.wa.gov/your-insurance/health-insurance/appeal/
A health
insurer's denial of treatment or a bill can
often be appealed, using this ... How to
appeal a health care insurance
decision: A guide for consumers in ...
bucks.blogs.nytimes.com/2011/07/11/7-steps-in-appealing-a-health-insurance-denial/
Jul 11, 2011 -
Most
insurance companies have at least a three-level
appeals process. ... by a medical director not
involved in the original claim
decision.
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