How to Fight an Insurance Claim Denial

How-to-Fight-an-Insurance-Claim-Denial

Do you figure the hassle of battling an insurance claim denial isn’t worth it?  Think again! According to a recent report from the Government Accountability Office (GAO), patients who appeal denials directly to the insurer win 39% to 59% of the time.  That’s not bad.

What’s more, the Affordable Care Act, President Obama’s healthcare reform law, requires most insurance plans to let you make an external appeal, in which a 3rd party rules on the case if a direct appeal fails. (Previously many insured patients had no such recourse).

To increase your chances of winning an appeal, consider these steps.

1. Check Errors.

According to the American Medical Association, 19% of claims’ payments have errors. Lots of doctors and hospitals bills do, too.  For example, there is a code for a check up for a 1-4 year old, but if your child is 6, the claim will be denied. 

If the letter doesn’t explain the reason for the denial, call member services and ask for more information, including asking for what codes were used. (They’ll know what you’re asking for, just write them down). Check them with your healthcare provider’s office to make sure they’re accurate. If not, ask the healthcare provider’s office to correct the claim and resubmit it.

 2.  Make Your Case In Writing. 

Other explanations for denials are that the care wasn’t medically necessary or was experimental or investigational or that you didn’t get pre-authorization.  In such cases, you usually have to file an appeal within 180 days. When making such a formal appeal, include:

A cover letter summarizing your argument and what’s in your appeals packet (Written by you).
A letter from your doctor explaining your diagnosis and symptoms, what other treatments you’ve tried, and what would have happened had you not gotten treatment. (You’ll need to request this).
Copies of your medical records back to the date of your diagnosis.  (You’ll have to coordinate this).
In the case of experimental or investigational denials, include studies published in medical journals that have found the treatment to be effective for patients in your situation (ask your provider’s office for help with this).
Mail the entire packet, with delivery confirmation, to the insurance company.  And please don’t forget to copy the packet before you send it.  That way you’ll have a record of it.

3.  Escalate The Battle.



If your insurance company won’t budge, make an appeal to an independent review organization that has the power to overturn your insurer’s decision. Your legal rights and the procedures to follow vary by state and by health plan so you will have to do a little more homework. (No one said this would be easy!)

When insurers deny an appeal, they sometimes rely on what’s called a clinical peer review.  Don’t be afraid to ask the insurance company for a copy of the review to check the qualifications of the person who performed it. For instance, If the case involves your elderly parent and a pediatrician did the review, you might consider challenging the credibility of the reviewer to render a decision.  We once had a case where a patient was having a gynecological issue and it was a radiologist making the decision on behalf of the insurance company.

Update your information packet to counter your insurer’s argument, then file it. If your case is deemed urgent, you’ll get a ruling within 72 hours; if not urgent, it may take up to 45 days.

4.  Bring in A Pro

When the stakes are high, like thousands of dollars, and you’re in a time crunch, consider hiring or enlisting the help of a patient advocate.  Guardian Nurses often get involved with cases where patients are appealing to their insurance company.  Sometimes when you’re so close to an issue, it is very hard to be objective because it’s personal and you’re invested in it.  Having a third party help out can often be more efficient and more effective.

Insurance companies COUNT on their members not taking the time or making the effort to challenge their decisions. Please be mindful of your claims when you are engaged with the healthcare system. It may be money IN your pocket!

 

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About Betty Long, RN

As a registered nurse working in greater Philadelphia-area hospitals over the past 27 years, Betty Long’s experiences as a nurse and manager proved to her that maneuvering through today’s healthcare system can be daunting, especially when you don’t have someone to help you navigate the system. Care decisions, insurance decisions and coordination of treatment services can overwhelm even the savviest consumer. Those experiences, and other more personal experiences, led Long to launch Guardian Nurses Healthcare Advocates in October 2003. Guardian Nurses provides advocacy services for clients, both private and corporate, all over the United States. The driving mission for its nurse advocates is simple: to act as representatives and advocate for their patients. And since nurse advocates work independently of hospitals, doctors, insurance companies and government agencies, they can be a strong voice for patients in all areas of the healthcare system. Nurse advocates understand healthcare issues from the viewpoint of caring for the patient and of the medical professionals trying to provide care. Nationally, Long’s advocacy work has been featured on The Dr Oz Show and National Public Radio’s Marketplace and Marketplace Money shows and various print publications. www.GuardianNurses.com

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