When a health insurer denies a claim, most people complain to their circle of friends and family, then roll over and accept it, arranging payments and resenting every minute of it. It was bad enough you had to wear that hospital gown, now the humiliation continues? After all, what can anyone do to fight against the big insurers and hospitals?
If you have health insurance through your employer, your human resources department may be willing to work through the claim and find a resolution. If not, or if your human resources department is just one person with a room full of file cabinets, you’ll have to take up the fight yourself. Here’s what you’ll need:
- A copy of your policy
- An itemized copy of your hospital and doctor’s bills
- A copy of authorization records for treatment
- A journal to keep track of who you spoke with (a spiral notebook will do)
- A chronological file with all correspondence from doctors, the hospital, and your insurer
- Copies of any checks you’ve already written
First, know your health insurance policy
Your first objective is to know your policy better than anyone. You have read it haven’t you? It’s critical that you know what is covered (according to the policy), what isn’t covered, the limitations of coverage, and all declared exclusions. If there is anything in it you don’t understand, call the customer service number and ask for an explanation. While you have them on the phone, ask about their formal appeals process and how to get it started.
The big secret: your doctor doesn’t know your policy
Doctors are in the business of patient care and she may make quick decisions (that are in your best interest by the way), thinking that she can always “backdate” the authorization. That doesn’t fly like it used to and you could find yourself inside a bureaucratic black hole with your health insurance.
1. Review your paperwork
Review your paperwork to make sure you did everything right. Once you’ve reviewed the paperwork, call your insurer. The customer service representative should be able to explain why your claim was denied at this point. Make sure you take great notes and log everything in your journal.
2. Administrative errors?
Your claim may have been denied because of an administrative or medical coding error. If that was the case, you might be able to solve the whole problem with just one phone call or letter from your doctor. Sometimes the doctor can resubmit your claim using a different medical code that IS covered.
3. Scrutinize your itemized bill from the doctor or hospital
Analyze every single charge (I was charged $12 for an Extra Strength Tylenol once!). There are often charges on these bills for items or services that were not delivered or performed. If you find a discrepancy, notify the doctor or hospital immediately and get the bill adjusted. Then, notify your insurer. It’s a good-will gesture toward them.
If the insurance company doesn’t consider your medical procedure necessary, or says that it was “experimental” or outside their coverage area, move on to step four:
4. Request a formal review
The customer service representative can tell you the specific procedures and paperwork they require to initiate a formal review of your case. Then, state your case for appeal in writing, and “go postal” on them. Send the letter via certified mail, return receipt requested. Do this the same day you request the review over the phone. Some companies have time limits on when appeal requests can be filed. Don’t wait around.
5. Get copies of your doctor’s notes
Your insurance company might claim the cost of your care was above their usual and customary cost (U & C), request copies of your doctor’s or surgeon’s notes. These jewels of information just may show that there were unusual or mitigating circumstances in your case to justify the extra costs. Also, request any other information you need from your doctor to prove your case, and make sure you have it all in writing. Your doctor should be very accommodating on this.
6. Appeal to a “higher authority”
No, not THAT higher authority, I’m talking about your state government. The Kaiser Family Foundation has some great information on every state’s health care rules.
- Some states mandate certain coverage even if not explicitly stated in your policy. The benefits you need may already be covered by law.
- Your state’s department of insurance should be able to inform you exactly how much assistance they can provide. Be sure to ask, and use their help in your fight.
- If you have been denied coverage due to a perceived (or contrived?) lack of medical necessity or because your insurance company considers your coverage “experimental or investigational,” most states now allow you to apply for an independent external review. Your state’s department of insurance will be able to inform you if your state is one of these.
- Some very large employers are actually self funded and they use the insurer on the front end for administrative purposes only. In this case, you may need to appeal to federal authorities. Contact the Department of Labor’s Pension and Welfare Benefits Administration, and they will consider your appeal. You have a chance of winning on appeal, especially if they find that the decision in your case was inconsistent with decisions made for other plan members.
Bear in mind that many of the claims denied by insurers are legitimate denials. In those cases, it pays to have additional health insurance to back up your primary coverage.