Fighting with health insurance companies has to be one of the most unsavory tasks around. When I worked in a cancer clinic, we had one woman whose sole job was to talk, negotiate, beg, and plead with insurance companies on behalf of our patients. It was never an easy fight, and one that most people have to do for themselves. Though it requires patience, attention to detail, and tenacity, taking the time to dispute a denial can really pay off. You just might win. A recent case in California brought against a managed care company found that 30 percent of medical claims were improperly denied; a study done by the Kaiser Family Foundation found that around 40 percent of disputed claims were approved. If you think your insurance company has wrongly denied a procedure, pursue it.
Before an insurance denial, try to prevent one. Though the jargon is thick and the terms confusing, reviewing your health insurance plan to determine whether a procedure is covered or not can save you the headache of trying to be retroactively paid. If you are going in for a surgery or a pre-scheduled procedure, oftentimes your doctor’s office will obtain pre-authorization for you—but don’t leave it up to them. Call your insurance office or follow up with your doctor’s office to make sure you have insurance approval, and ask to have the approval information sent to you in writing.
Make Sure Your Claim is Valid.
When you receive a denial letter, either for a procedure that has yet to be performed or for a claim that has already been submitted, check with your plan to see if this procedure, drug, or treatment is explicitly covered or not. If your plan clearly indicates it will not cover this procedure, then you may have a hard time fighting the denial. However, if the procedure is not mentioned explicitly, or there is room for interpretation, then you may have a valid case.
Gather All of Your Paperwork.
Gather plan information, explanation of benefits, letter(s) of denial, doctor’s bills, referrals, and medical records. You may need to request a letter from your doctor to signify a treatment is medically necessary. Start a folder to keep paperwork in order and handy. Many insurance companies require that you dispute claims within a certain amount of time; having everything in one spot will help facilitate this.
Call Your Insurance Company for an Informal Appeal.
When you call, explain why you are challenging the denial. Make sure all the information on your denial was accurate (especially your diagnosis). Write down the name of the person you speak with, and ask for a date when you should expect to hear back from the person. Write this date on your calendar, and give them a call back if you haven’t heard from them by this date. Be sure to keep a log of all phone interactions with the insurance company (name of representative, date); this may be needed if you take legal action later.
Make a Formal Appeal.
If your informal appeal didn’t work, you’ll need to submit a formal appeal in writing. Most plans have guidelines as to how to do this and some have specific forms, but generally you will need to submit a letter requesting to have your claim looked at. Many plans require you do this within a limited period, so make sure this letter gets in before the appeal date closes. In your letter, you will definitely need to include basics like your contact and insurance information, description and dates of service, supplementary information about why the service should be covered, recommendations from doctors, and references to benefit packages that support covering service. Furthermore, if the procedure is standard of care for your treatment or is covered by law under Medicare, you may want to include this.
If you are still not satisfied with your insurance company’s decision, you may appeal to an outside group. This is usually your state department of insurance. The laws vary widely by state (see state-by-state external review programs), but usually an independent body will review your case, and if they deem your treatment necessary, your insurance company will be required to cover it.