A letter arrives in the mail. oh great: it’s from your health insurance company. contains some variation of the phrase “your claim has been denied” and possibly “you may file an appeal to challenge this decision”. There’s also probably an alarmingly large dollar amount with “patient liability” next to it.
take a deep breath. You’re not committed to this bill yet, and you probably didn’t do anything wrong to make this happen. there is a process for her insurer to re-investigate this before she has to pay anything.
Reading: Insurance claim denied what next
It may all sound too daunting to handle, or it may not be clear what steps you need to take.
“Health plans are not consumer friendly, and plan documents are often full of fine print and legal jargon, which is intimidating to many people,” Ashira Vantrees, Staff Attorney, Targeted Alliance, a non-profit organization that advocates for health care. consumers and providers, he wrote in an email. “Furthermore, while most benefit denial letters should include information about an appeal process, not all do; therefore, many people may not even know that they have the right to appeal.”
a 2019 kaiser family foundation study found that people who get their coverage through the healthcare.gov Affordable Care Act had appealed less than 0.2% of in-network denials .
But if you file an appeal, your chances of getting that claim covered are decent: The same study showed that 40% of people who started the appeal process with their insurer were successful. An analysis of California data from 2014 showed that patients who appealed through a third party won about half the time.
People, including this reporter, rarely get into a bureaucratic dispute with their health insurance provider, describing the process as “straightforward” or “easy to understand” or “resolved quickly.” so it’s easy to see why some people just accept denial.
“Fighting an insurance company can be exhausting. Health insurers often make appeal and reimbursement processes difficult,” Vantress wrote. “For many people, it can be less draining to give up and accept a different treatment or medication, pay out of pocket, or not get treatment at all, than it is to expend energy fighting with your health plan.”
Still, it may be worth fighting back. sometimes it’s a simple paperwork problem that your doctor’s office can handle: a multi-digit billing code entered incorrectly, a tax ID entered in the wrong box, a standard lab procedure that might be coded differently than get it covered.
It’s your money they’re trying to keep. defend it. here’s how.
the appeal process
“appeal process” it sounds like you need to hire an attorney to file a supreme court case on your behalf. what you’re really doing is telling your insurer, “hey, I think this should have been covered and I want you to look at it again.”
You may be wondering why you need to get involved. Your doctor billed your insurer for something they decided you needed. You had nothing to do with the paperwork. why is it your job to look up the corrected billing codes? surely your insurance company could contact your doctor’s office directly and figure this out?
yes, they could. But “that would cost them a little more money,” said Libby Watson, who writes the Substack newsletter’s sick note on the various indignities of the American health care system. “It’s much easier for them to just deny it and hope the person doesn’t appeal it.”
Your first step will be what is called an internal appeal.
Internal Appeal: You have the legal right to force your insurer to review your claim again. this is called an internal appeal. again: this sounds intimidating. But really, all you’re doing is finding out why your claim was denied, contacting your doctor for help, and submitting the information your insurer needs for the claim to be processed correctly. that is all.
“Many times, it will be a lot easier than you think,” Watson said.
Review the letter that says your claim was denied and find out why it was denied. It may also include instructions on how to appeal the decision or have the claim reviewed. This could mean providing more information to the insurer, and that could mean calling your doctor’s office and asking them to resubmit forms, correct a billing code, or provide a more detailed rationale for why a procedure, drug, or test is medically appropriate. necessary.
If the letter you received doesn’t describe the appeal process, call your insurer’s customer service (phone number on your health insurance card) and ask. You can also search your insurance company’s website, or try searching “appeal process (insurance company)” for more information. the targeted alliance runs coverrights.org, which contains state-by-state information on how to challenge your insurer’s decision and escalate complaints. about the process.
It’s a good idea to take detailed notes. write the date you received the letter, the date you filed your appeal, the date and time you called your insurer, and the name of the representative you spoke with. you may need to refer to these details later.
Your doctor’s office should be your partner in this process. contact them and let them know your claim was denied. they will probably be able to help. For example, if your insurer found the drug or procedure not medically necessary, your doctor’s office should be able to send any additional information needed to show why it is.
Once you have gathered all the information requested in your insurer’s letter, submit it as your appeal. You may also need to include a letter explaining the reasons for your appeal. The National Association of Insurance Commissioners has an example of what that might look like.
If your life, health, or ability to function may be in danger because of a denial, you can request that your appeal receive an expedited review.
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External Appeal: If, after your internal appeal, your insurer says, “no, we’re still denying this,” you can ask an independent organization to take a look at it. Usually, this will be your state’s insurance regulatory agency. the internal appeal denial should explain how to begin that process.
The external appeal may include new information in your defense, so contact your doctor again and let him/her know what is happening. they may have more information for you to include.
within a certain period of time, an external review will be carried out. if the reviewer decides the claim should be covered, your health insurer must comply.
Do I need a lawyer? not necessarily. There are attorneys who specialize in insurance claim denials, but like all attorneys, they cost money. If you’re going to lose your home if you have to pay this bill, it’s probably worth an hour legal consultation to see how they can help you; if it’s a few hundred dollars in lab fees, it probably isn’t.
I still have a problem. What I can do? if you think the process is not being handled fairly, you can file a complaint with your state insurance commissioner or the federal department of labor. the targeted alliance’s coverrights.org website has state-specific information on filing complaints. If your health insurance is through your job, contact your human resources representative and let them know what’s going on. your employer contracted with this insurer to provide this service and should be able to help you move forward.
why denials happen
Your doctor decides you need something. why can your insurance say otherwise?
“Health plan coverage denials happen because health plans are trying to save money, which increases their profits,” vantrees wrote.
“It’s a ridiculous cycle that drives up the cost of health care in general, and it’s a waste of everyone’s time, and I don’t think it even drives down insurance costs that much anyway,” Watson said.
I posed the question to a spokesperson for the Centers for Medicare and Medicaid Services, who had a more circumspect written response: “when a consumer files a claim for coverage of an item or service, the group health plan or Individual marketplace issuer may deny coverage in whole or in part for the claim because the plan or issuer decides that, under the terms of the plan or coverage, the item or service is not covered.”
so they can deny coverage for something because they decided it’s not covered. good.
Even getting prior authorization for a service or drug isn’t necessarily enough to avoid a so-called “retrospective denial” later on, as a 2020 kaiser health news investigation shows.
Is anything being done about it? A bill called the No Surprises Act went into effect this year. Does that mean no more “claim denied” surprises? No. In a recent issue of Sick Note, Watson noted that it might more accurately be called the “act of least surprises.” the bill aims to eliminate a very specific type of health care surprise, which is when you visit an in-network hospital but get a separate bill from an out-of-network provider you didn’t choose, like an anesthesiologist. /p>
so individual claims can still be denied. But with the knowledge, patience, and willingness to make a few phone calls, you have at least a chance of keeping some or all of your money.