Stay true to this principle and you can improve your odds of successfully fighting a health insurer’s claim rejection.
Experts who help with the appeals process say patients have a 50 percent chance or better of prevailing. They say a winning argument may require heavy doses of research and persistence, but the end result is a decision that can stave off thousands of dollars in medical bills.
Certainly understanding the limits of your insurance, before you seek care, will help you avoid the frustration of having your claim denied. But if you get to the point where you need to appeal, here are some important points to remember.
1. STARTING AN APPEAL: Learn all you can about why your claim was rejected and don’t be afraid to ask questions.
If the insurer deems your care to be not medically necessary, request an explanation that includes the insurer’s policy language and any information used in making the decision. Keep records of who you spoke with and when.
“Take down notes and get the language down as cleanly as possible,” said Stephen Parente, a professor of health finance and insurance at the University of Minnesota.
Maintaining a calm demeanor can help you think rationally, and it may make customer service representatives more inclined to help.
Learn the insurer’s appeal process, including any deadlines. A missed deadline can sink an appeal regardless of how strong your case is.
2. BUILDING YOUR CASE: Sometimes a claim is denied due to a clerical error, such as the wrong code being used for a medical procedure.
A good starting point is to check with your provider’s billing office to make sure your claim was coded correctly. If something is amiss, you can probably get it cleared up with a few phone calls.
Other cases may require an appeal letter. Your letter should lay out the reasons you believe your care should be covered. Ask your doctor to review your argument and offer input.
A physician can help detail how all treatment alternatives were exhausted before you started receiving the care an insurer deemed not medically necessary.
The insurer will want more than your doctor’s word, so be prepared to include any confidential medical records that support your case.
Consider including medical journal articles that support your argument or detail the effectiveness of your treatment. These can be especially helpful if your doctor is unable or unwilling to work with you on the appeal. Patients can use the National Institutes of Health website pubmed.gov to search journals around the world.
Make sure you directly address the insurer’s reason for denying coverage. Not doing so is the biggest mistake people make in filing appeals, according to Cheryl Fish-Parcham, private insurance program director for the health advocacy group Families USA.
Submit your appeals by certified mail so you can document when the insurer receives them and that you met any specified deadlines.
Be persistent. If the first appeal doesn’t work, the insurer should outline additional options that may include an appeal to a medical director who was not involved in the decision.
The insurer also may permit a peer-to-peer review, in which your doctor talks to a physician representing the insurer about your case.
3. GOING OUTSIDE THE INSURER: If you’re not happy with the insurer’s internal review, seek an examination from an independent reviewer. Be mindful of any deadlines for making such a request.
Some patients with employer-sponsored health plans also may be able to turn to their company for help. Companies with self-funded coverage – largely those with 200 or more workers – actually pay the medical bills and hire insurers to administer their plans.
The employer may learn through your appeal that its coverage is more limited than what company leaders intended, said Erin Moaratty, chief of mission delivery for the Patient Advocate Foundation, a nonprofit organization that helps patients with medical bills and coverage denials.
Even if the employer declines to overturn the insurer’s decision, it can be important for companies to be brought into the appeals conversation so that they can consider making coverage adjustments over time.
Check with your human-resources department to see if your coverage is self-funded and if they can help you understand the appeals process or put you in touch with the right insurance representative.
4. SEEKING HELP: If you’re not comfortable shaping your argument, or you’re not physically up to it, you have a few options for outside help.
Some states offer consumer assistance programs, and your insurer should provide you with contact information for the program in your state.
Help is also available from nonprofit agencies such as Patient Advocate Foundation and The Jennifer Jaff Center, which can assist with appeals in cases involving chronic, life-threatening or debilitating illnesses.
For-profit companies like Medical Billing Advocates of America also work on insurance denials. A spokeswoman said its fees depend on the amount of time spent working on the case.