The Smart Patient's Guide to
Chronic Pain Management

Fighting Back: What To Do When Your Health Insurance Company Denies A Claim

While taking on an insurance company isn’t fun, we hope the tips gathered here will make the process easier and increase your chances for a successful outcome.

This article is Part 2 of a series. Read Part 1: 7 Strategies to Help Avoid Health Insurance Claim Woes

When an insurance company rejects a pre-authorization or denies you coverage for a pricey treatment you’ve already received, you may want to crawl into bed and pull up the covers. That’s just what insurance companies want you to do! Insurers bank on people not disputing denials, says Deborah Bain, RN, managing director of Prism Health Advocates, a company that assists clients with health insurance denials and disputes. Successfully challenging a claim denial takes tenacity, but don’t despair. Persistence pays off more often than you think.

For example, according to data from the California Department of Managed Health Care released by National Nurses United:

  • 60% of cases insurers denied as “not medically necessary” were either overturned by independent medical review or ultimately reversed by the insurer
  • 80% of cases insurers denied as “experimental” or “investigational” were overturned or reversed by the insurer
  • 52% of cases where insurers refused to authorize payment for emergency or urgent care provided to a patient were overturned or reversed by the insurer.

Moreover, a report published by the US Government Accountability Office reveals that in the four states that track such data, 39% to 59% of private health insurance appeals resulted in reversal. While these stats are both state and insurer specific, the important—and reassuring—takeaway is that appealing a denial is worth the aggravation.

What You Can Argue Against

Sometimes it’s the simple things that trigger insurance denials—incorrect coding of procedures, transposed policy numbers, a misspelled name, the wrong address or any number of other technical errors. The good news is that these errors can usually be resolved through a phone call to the insurer as explained in Part I of this series.

When a simple error isn’t the cause, a denial can be triggered for various reasons. Some of the most common culprits include:

  • The treatment is considered not medically necessary.
  • The drug or therapy is non-formulary.
  • The drug or treatment is considered “experimental.”
  • The service or treatment is not covered under the plan language.
  • The care you received was provided by an out-of-network provider.
  • The benefit is not covered under your health plan.
  • The therapy did not adhere to the plan’s treatment requirements.
  • You did not get pre-authorization.

Rules of Denial

The explanation for the denial of your claim must be spelled out along with information on how to file an appeal and any other steps you need to take. These steps should also be in your plan’s Explanation of Benefits (EOB). If you don’t understand the explanation, call the insurance company for clarification. 

Tip: Whenever you contact your insurance company, take notes and names and write down the date and time, what was discussed and ask for a reference number. You may also want to create a call log.

The Appeals Process

According to the Patient Advocate Foundation, there are three “levels”—two internal and one external—to the appeals process. Some plans require a second internal appeal before proceeding to an external appeal.

Level 1: First Internal Appeal (Request for Reconsideration)

You and/or your provider fill out any paperwork and follow any steps required by the plan. Your written response should address the reason your claim was rejected. If the claim was denied because the procedure, therapy or medication was considered “experimental,” it’s important that you provide evidence that, contrary to the insurer’s interpretation, the treatment is both medically necessary and frequently used.

Always ask your doctor or other providers to write a letter explaining why the treatment is medically necessary, the negative repercussion on your health and well-being if you do not get the treatment, and the potential cost savings over time.

To bolster your case, attach one or two relevant peer-reviewed, published studies that support the efficacy of the medication, treatment, or procedure (this is especially important if your claim or request for pre-authorization was denied because the insurer considers the treatment or medicine as “experimental.” In that case, you need proof that the treatment is being used in general practice.) PubMed is a great resource for this task. Always keep a copy of letters and documents that you submit, and always send correspondence by certified mail with return receipt. Proof that the appeal was sent and in a timely fashion is essential.

Tip: The Affordable Care Act (ACA) requires insurance companies to respond within certain timelines:

·      72 hours if your claim is for urgent care,

·      30 days for treatment you haven't received yet,

·      and 60 days for treatment you've already received.

You can find examples of appeal letters and templates online. MedicalClaimsHelphas samples for 17 different types of denials.

Level 2: Second Internal Appeal

While some plans may require a second internal appeal, usually it’s up to you to pursue or go directly to an external appeal. The insurer is required to inform you of their appeals process. The plus side of a second level internal appeal is that it’s more likely the appeal will be reviewed by a higher level person, a clinician or plan administrator.

As with the first appeal, include all relevant correspondence, plus the insurer’s denial letter and your response. When writing a letter, keep your argument focused on your health and long-term benefits. Your argument needs to be calm and compelling, but forceful. In the appeals process, your doctor is your best ally. Have your doctor “step up” his or her argument on your behalf.

“You want the doctor to focus on the seriousness of the situation; the detrimental impact on your health if you are unable to have the procedure, the treatment, the medicine and the physician’s explanation of what could happen to this patient if he or she is denied treatment, medication or service,” says Adria Goldman Gross, CEO of Medwise Insurance Advocacy.

Tip: Copy all your documentation and send by certified mail with a return receipt. Your physician can also request a “peer to peer” consultation, a discussion with a doctor, to explain why the procedure or treatment is medically necessary. Ask your doctor to provide you with a copy of his or her notes from the conversation, including whom he spoke to, the peer’s specialty, and contact information.

Level 3: External Appeal

If your internal appeals fail, you’re not stuck yet. You’re entitled to an external appeal, which means that your claim will be reviewed by an independent party or by a reviewer at the Department of Health and Human Services if your state does not have an independent review system in place. According to the National Association of Independent Review Organizations, it is the insurer’s duty to notify consumers in the final adverse determination letter about their external review rights, how and where to file an appeal, and the types of denials suitable for an external review. According to HealthCare.gov, these include:

  • any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
  • any denial that involves a determination that a treatment is experimental or investigational
  • a cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage.

If the claim denial involves a substantial amount of money, it may be worth enlisting the aid of a healthcare advocate to help you present the best possible case for a reversal of fortune. You can always enlist the help of a lawyer, but make sure he or she specializes in health insurance.

Tip: The length of time allotted to file a written request for an external appeal seems to vary by state and may depend on which agency will handle the appeal. Usually, you must file a claim for an external appeal; within 60 days of the date your health insurer sent you a final internal adverse benefit determination. If you have questions about the appeals process, The National Association of Insurance Commissioners and Consumers Union provide state-by-state guides that identify the appropriate agency in your state.

Updated on: 08/21/18
Continue Reading:
7 Strategies to Help Avoid Health Insurance Claim Woes
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