Posted : 04/09/2012
Fighting a health insurance company over a claim denial might sound like a David vs. Goliath struggle, but the battle is worth waging if you've got a legitimate case -- and winning is easier than you might think.
Health insurance companies in most cases aren't out to cheat you. Many wrongful claim denials stem from coding errors, missing information, oversights or misunderstandings.
Here are six steps for winning an appeal:
The insurance company should send you an explanation of benefits form that states how much the insurer paid or why it denied the claim.
Call the insurer if you don't understand the explanation, says Katalin Goencz, director of MedBillsAssist, a claims assistance company in Stamford, Conn.
If it's a simple error, the insurer might offer to straighten it out. But double check to make sure your insurer follows through, Goencz says.
"Get the name of the person you spoke to, the date, the reference number for the phone call, and put it on your calendar to check back with the company in 30 days," she says.
Understand exactly what is covered under your policy and how co-pays are handled. Health insurance plans differ. For example, find out if you have an HMO or a PPO. Usually the health insurer includes a summary of benefits online, but you should read the policy itself, says Rebecca Stephenson, president and CEO of VersaClaim, a claims assistance and patient advocacy business in Austin, Texas.
"This is not a document you store in the attic with your old tax records," she says. "It needs to be close at hand."
Can't find it? Ask the employee benefits department or your broker for a copy.
Read your health plan and learn the rules for filing an appeal.
"You want to know how under the gun you are," Stephenson says.
If it's a complex case and you're concerned about meeting the deadline, send a letter stating you're appealing the denial and will send further information later, Stephenson says.
Gather documentation to back up your argument. Sometimes the problem stems from something as simple as a billing mistake by a doctor's office.
Stephenson tells of one client whose health insurance company denied a claim for surgery because her deviated septum was named as the diagnosis. The insurer did not cover surgeries for a deviated septum.
But she was also diagnosed with acute purulent sinusitis -- the real reason for the surgery, which was never communicated to the insurance company.
Stephenson had the client submit copies of her medical reports, X-rays and a letter from the physician confirming the sinusitis diagnosis. The patient won.
When you write an appeal letter, be sure to include your address, name, insurance identification number, date of birth for the person whose claim was denied, date the services were provided and the health insurance claim number, Goencz says.
"The first sentence should state that you are appealing the claim denial, and the body of the letter should explain why the medical bills should be paid," Goencz says. "Put in a closing sentence demanding payment, and include supporting documentation."
Save emotional rants for understanding friends, and stick to the facts.
"[Insurers] don't want to know about your grief and how sick you've been," Stephenson says.
Send by certified mail to get notification that the packet was received, she adds.
"If you lost your first appeal, you've got to step back and look at why the health insurer is saying no," Stephenson says. "What other information do you need to give them to state your case?"
Then, follow the health plan's procedures for filing a second appeal.
If you exhaust the appeal process and are still unsatisfied, you can take the case to the state department of insurance, unless your coverage is through an employer that is self-insured. In that case, your next stop is the U.S. Department of Labor, although both Goencz and Stephenson say getting federal officials to act is a long shot.
Overwhelmed? Hire a professional patient advocate or claims assistant. You can get names of claims assistance professionals in your area through the Alliance of Claims Assistance Professionals.
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