Appealing a health insurance claim denial is not always an uphill battle if you follow the correct procedures and present a good case.
A denial of a health insurance claim may result in an unexpected medical bill, but it is not the last word. Insurers and states have health insurance appeal processes so you have a chance to have a say.
Surprise medical bills are a growing concern. a recent jama study said ambulance transports, hospitalizations, and emergency room visits are especially problematic.
A health insurance claim denial can occur for many reasons, and often they can be resolved. Here’s why a health insurance claim can be denied and what to do about it.
common reasons for denial of health insurance claims
When insurance refuses to pay a claim, there can be several reasons:
- a provider or facility is not in the health plan’s network.
- a provider or facility did not submit the correct information to the insurer.
- The health plan needed more information to pay for services.
- The health plan did not consider a procedure medically necessary.
- an administrative error.
- your letter of medical necessity
- a copy of your denial letter
- other supporting documents before the deadline
- why your appeal was approved or denied
- the basis for the decision
- the next step in the appeal process
cheryl fish-parcham, director of access initiatives at families usa, a nonprofit that advocates for affordable and accessible health care, says a clerical error is often to blame.
“A large group of claims are denied due to coding or billing errors that can be easily corrected by the doctor’s office,” he says.
fish-parcham adds that you can dispute denied claims that the insurer alleges are not covered by the policy.
“People should see what the plan documents actually say about whether a benefit is covered and get help from their insurance department or an expert consumer assistance program if they have any questions,” says fish-parcham.
The denial rate of health insurers varies. A recent study by Harmony Healthcare found that claim denials are on the rise in hospitals, averaging between 6 and 13%. Meanwhile, an analysis by the Kaiser Family Foundation found that plan denials from the health insurance marketplace are even more frequent at 18%.
how to appeal a health insurance claim denial
Fighting a health insurance company over a claim denial may sound like a David vs. Goliath fight, but it’s worth the fight if you have a legitimate case. plus, winning is easier than you think.
many unfair claim denials stem from coding errors, misinformation, oversights or misunderstandings.
pat jolley, director of clinical initiatives for the patient advocacy foundation, says your insurance company will send you a denial letter explaining why when a claim is denied. the denial letter will provide the appeal process and the deadline to appeal.
what to do if a health insurance claim is denied
then your doctor ordered a test or treatment and your health insurance claim denied it. now what? How do you dispute a health insurance claim denial? See the steps below to learn how to fight a health insurance claim denial:
1. find out why the health insurance claim was denied.
The insurance company must send you an explanation of benefits form that shows how much the insurer paid or why the claim was denied.
Call the insurer if you don’t understand the explanation, says katalin goencz, director of medbillsassist, a claims assistance company in stamford, connecticut.
If it’s a simple mistake, the insurer might offer to fix it. But double-check to make sure your insurer qualifies, says goencz.
“get the name of the person you spoke with, the date, the reference number of the phone call and put it on your calendar to check back with the company in 30 days“, He says. .
2. read your health insurance policy.
Understand exactly what your policy covers and how copays are handled. health insurance plans differ.
for example, find out if you have an hmo or a ppo. The health insurer usually includes a summary of benefits online, but you should read the policy itself, says Rebecca Stephenson, president and CEO of Versaclaim, a patient advocacy and claims assistance company in Austin, Texas. .
“This is not a document you keep in the attic with your old tax records,” she says. “it has to be within arm’s reach.”
can’t find it? Request a copy from your employer’s benefits department, health insurance company, or broker, depending on how you get insurance.
3. know the deadlines to appeal the denial of your health insurance claim.
read your health plan and understand the rules for filing an appeal.
“You want to know how under pressure you are,” Stephenson says.
If it’s a complex case and you’re worried about meeting the deadline, send a letter saying you’re appealing the denial and will send more information later, Stephenson says.
4. make your case.
Gather the necessary paperwork from your health care provider.
“Get a letter of medical necessity from your health care provider that describes why the recommended treatment you received was medically necessary,” says Jolley.
In cases where you are denied because the service or treatment you received was not covered, please provide peer-reviewed medical studies to support your case that the service was medically necessary. If you initially got a second opinion and the provider recommended the same treatment, use that as evidence for your appeal.
If you need additional evidence, fish-parcham says that “consumers can contact professional societies or disease associations to gather additional information about why and when a particular type of treatment is considered medically necessary and best practice.”
Sometimes the problem stems from something as simple as a billing error at a doctor’s office.
stephenson tells of a client whose health insurance company denied a surgery claim because his deviated septum was named as the diagnosis. surgery for deviated septum was not covered by the insurer.
but she was also diagnosed with acute purulent sinusitis, the real reason for the surgery, which was never reported to the insurance company.
stephenson had the client submit copies of his medical reports, x-rays, and a doctor’s letter confirming the diagnosis of sinusitis. the patient won.
5. write a concise appeal letter.
When writing a health insurance appeal letter, be sure to include your address, name, insurance identification number, date of birth of the person whose claim was denied, date services were provided, and the number of health insurance claim, says goencz.
“The first sentence should state that you are appealing the claim denial and the body of the letter should explain why the medical bills should be paid,” Goencz says. “Insert a closing sentence demanding payment and include supporting documentation.”
Include details about what you are appealing and why you think your claim should be paid.
“You have to appeal based on why something was denied. So if something was denied because it’s not a covered service, saying something is medically necessary doesn’t count,” says Jolley.
Save the emotional tirades for sympathetic friends. stick to the facts.
“[Insurers] don’t want to know about your pain and how sick you’ve been,” Stephenson says.
send by certified mail to receive a notification that the package was received, he adds.
This is what you can send:
Keep track of everything so you have proof of when you submitted your appeal. Save all electronic communications and write down the names and dates of everyone you talk to.
6. follow up if you don’t get a response.
Follow up with your insurance company 7 to 10 days after you submit your appeal to make sure it gets through, Jolley says.
Once you submit an appeal to your insurer, another medical professional, who did not initially review your claim, will verify all of the information on your appeal. Jolley says she can request a board-certified reviewer in the medical specialty associated with the claim.
The time it takes for your insurer to review your appeal varies. could be as fast as 72 hours. it could take 60 days. the time depends on the insurance policies.
once your insurer makes a decision, you will receive a written notice, which will include details about:
“each level of appeal you go through, you will get an actual approval or denial letter from the insurance company, and in the denial letter it will tell you exactly what your next step is and the next level of appeal to directs. to,” says jolley.
There are at least two or three levels of internal review you can go through with your insurance company before seeking external review, Jolly says.
7. if you lose, be persistent.
Once an external review is complete, you will receive a letter informing you that your rights of denial have been exhausted. After this, you may have the option of pursuing the matter through your state insurance commission or filing an appeal in federal court if you have a US Retirement Income Security Act health plan. employees (erisa).
If your appeal is denied, find out why the health insurer denied the appeal. “What other information do you need to give them to make your case?” stephenson says.
then follow your health plan’s procedures for filing a second appeal.
If you exhaust the appeal process and are still not satisfied, you can take the case to the state insurance department, unless your coverage is through an employer that is self-insured. in that case, your next stop is usa. uu. department of labor, though both goencz and stephenson say getting federal officials to act is a long shot.
If you need additional help, some states have consumer assistance programs to help navigate the appeals process. fish-parcham says the “explanation of benefits” in your plan summary may include the names of these programs. If you have an employer-sponsored plan, check with your human resources department to see if the programs patient guide can help you with appeals. process.
overwhelmed? Hire a professional patient advocate, health insurance attorney, or claims assistant. You can get names of claims assistance professionals in your area through the Alliance of Claims Assistance Professionals.
what is a prior authorization?
An insurer can deny you even before a test or procedure through the prior authorization process. Health insurers created the prior authorization process as a way to limit care they deem unnecessary.
With prior authorization, your health care provider must obtain approval from the insurer. for example, your doctor may want to do an MRI if he detects a mass in one of your organs. however, your health plan may want to review your medical records before approving the request. they do this to make sure an MRI is necessary for your specific case.
Some studies and surveys have indicated that prior authorization may affect patient care. in a survey, 93% of radiation oncologists said patient care was delayed. a third of them also said that they decided on a different treatment for 10% of patients because of these delays. however, health plans argue differently. point to studies indicating that up to 30% of medical care is unnecessary and that doctors sometimes prescribe the wrong treatment.
cathryn donaldson, a spokeswoman for health insurance plans in the united states, says prior authorization is not intended to hinder patient care.
“Just as doctors use scientific evidence to determine the safest and most effective treatments, health insurance providers rely on data and evidence to understand which tools, treatments and technologies best improve a patient’s health” says donaldson.
Health insurers are collaborating with doctors, hospitals, medical groups and other care providers to improve prior authorization. Donaldson says that Ahip and these groups “are committed to timeliness. In fact, most prior authorizations are approved within 72 hours for urgent care and less than two weeks for non-urgent care.” /p>
how to appeal a prior authorization denial
You have several options if your insurer denies you prior authorization.
“You can gather more medical evidence and appeal, first informally and then by following the formal procedures outlined in the notices you receive from your insurance plan,” says fish-parcham. “before you file the formal appeal, take enough time to understand the reasons for the denial and gather evidence to refute those reasons, but don’t hesitate to work with your doctor or other provider to informally pressure the plan to revisit the decision “.
If you submit all of this evidence and your insurer still denies your appeal, there are several things you can do. You can file a lawsuit against your insurer, but that approach is incredibly expensive and time-consuming. a better option may be to go through your state’s appeal process.
Most states allow consumers to request an independent review of their claim. During this process, an independent physician will review the insurance company’s decision and make a final decision on your claim. check with your state insurance department to find out when you can request an external review. In Massachusetts, for example, you can request an external review up to four months after you receive a letter from your insurance company denying your appeal.
As a consumer, it is important to understand the appeal and review process after a claim denial. Jolley says that all consumers should know that they have the right to appeal. studies have shown that appeals are often more successful than unsuccessful.
The Advisory Board Hospital Admissions Comparative Study found that between 29% and 59% of appeals to commercial insurance companies are successful. So if you get a denial letter from your insurance company, it doesn’t hurt to take the time to challenge it.