Every health-care consumer dreads getting that notice in the mail stating that his insurance company has denied a recent medical procedure. Unfortunately, most people automatically accept the denial without submitting an appeal. This is a mistake. According to the Government Accountability Office, patients who appeal denials directly to their health-care provider win 39 percent to 59 percent of the time.
Maryland is one of the few states whose insurance regulator tracks data on denials and appeals of health-insurance coverage, and it found that 15 percent of health claims submitted by state residents are denied. Only 14 percent of these denials are appealed. However, roughly half of those appeals are successful. This suggests that, if one of your claims is rejected, it is worthwhile to submit an appeal.
No one likes to participate in a bureaucratic process. But sometimes you can succeed without going through a complicated paperwork process. I have succeeded in more than one instance with a few phone calls, and generally I have found that when paperwork is necessary, it's the health care provider who takes care of it. For example, if your doctor's office has made a mistake in its submission, it resubmit the claim, not you.
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If you are notified of a denied claim, the first step you should take is to call your insurance company. Before calling, make sure to review your written policy, so you understand your coverage. When you call, don't specify right away that there has been a mistake (even if you think there has been). Instead, ask for a comprehensive reason as to why the claim has been denied. If the answer given is ambiguous, ask for a supervisor. Based on your reading of the policy, and on the explanation you're given, determine whether you think the claim has been denied for a legitimate reason.
There are three possible scenarios:
1) The denial was based on a legitimate reason, in which case you may choose not to appeal.
2) The denial was based on a faulty submission, such as the wrong code being entered on the claim paperwork. In this case, ask your health-care provider to resubmit the claim.
3) The claim was legitimate, and it was properly submitted. In this case, ask the health-care carrier, by phone, to reverse its decision; if it won't, then file the necessary formal appeal.
If your insurance is obtained through an employer, you should work with the benefits manager or the designated human-resources representative to get the denial overturned. If the insurance company wants to continue doing business with your company, it is in its interest to work closely with your benefits department.
It is necessary for you to understand the appeals process, as outlined by your policy. For example, you need to know what your rights are in the appeal process and how promptly do you have to file a written appeal. (Within 30 days? Sixty days?) You should make your letter as strong as possible, with an emphasis on showing how the procedures in question are consistent with your written policy. Letters of support from your providers (physicians, dentists, nurse practitioners, etc.) are very helpful. The physician should explain his or her diagnosis and treatments used, as well as the probable results had the treatment not been done. You should include copies of previous medical records if applicable. When you mail the package, make sure you get delivery confirmation.
An excellent resource for appeals, "Your Guide to the Appeals Process," is available at www.patientadvocate.org
If your appeal is unsuccessful, determine your available options. This will depend partly on state law. One option may be an appeal to an independent third-party reviewer working with your health-care provider. Last year's health reform law requires most plans to allow you to make such an external appeal. Another option may be review by your state's insurance department.
If all appeals fail, and there are significant financial consequences, you can solicit the advice of an attorney who specializes in health insurance issues.
Contact columnist Elliot Raphaelson at elliotraph@gmail.com