One of these days, you might
have to battle your health insurance company over a denial of coverage.
course, most people would rather skip the fight, and there are steps you can take
to avoid health insurance denials before they occur.
And if that doesn't
work, there are steps you can take to fight them once they do.
The key is organization -- having all your paperwork in order, taking detailed
notes of your interactions with everyone in the process and understanding your
Knowledge -- your best weapon
Information is power, and this is never truer than when battling a health
care system. The winner may be the side with the better-organized, more-detailed
Some experts feel that legislation is tilting
the regulatory environment in the patients' favor.
environment is becoming more consumer friendly as more states and health plans
adopt independent review processes," says Larry Gelb, president and CEO of
CareCounsel LLC, a health care advocacy group.
Even so, the
best bet when dealing with insurers is to minimize the risk of denial, and then
if one does come your way, to solve the problem in the early stages.
are some steps to help avoid denials of coverage by your health care provider
before they occur.
- Understand your policy thoroughly.
Review it on a regular basis, and ensure that you know exactly what is covered
and what isn't. If you have questions or don't understand any aspect of your coverage,
call your insurance company and make them explain it in layman's terms. Make sure
you understand the exclusions and limitations of the policy, and the section on
how to appeal.
- When receiving medical care, make
sure your health care provider understands what is covered and what is not. Remember,
doctors deal with many patients and many insurance companies. Don't assume they'll
remember the particulars of your situation.
your policy provisions seriously. If it dictates that prior authorization is required,
then don't receive care without obtaining that authorization. Assuming that the
company will cover you and you can obtain coverage later, even if that is what
your doctor tells you, could lead you into a world of bureaucratic hell, and might
lead to a denial of coverage.
- Keep detailed notes!
This cannot be overstated. Take notes of every aspect of the process -- when you
received authorization and from whom, the day you received treatment, what you
discussed with your doctor, what action was taken and what follow-up is required.
Every phone call made, person spoken to and action taken needs to be documented,
including all names, dates and places.
- Save copies
of all paperwork from your doctor and your insurance company. Keep these records
in chronological order for easy location.
- If using
an out-of-network provider, establish before care is provided that they will accept
your health insurer's payment in full.
- If there
is a claim for which your insurance company will reimburse you only after you've
paid your provider out of pocket, be sure to file the claim immediately.
- If there is a delay in payment, call your insurance
Assuming you've taken all these steps and are still denied
coverage, do the following:
- Review all the paperwork
regarding the case immediately, making sure you understand every aspect. Then,
with your paperwork in front of you, call your insurance company. Use the customer
- The insurance company rep should
be able to tell you why you were denied coverage. Make sure you take detailed
notes of the conversation!
- Denial of coverage
is often a result of administrative error. If this is the case, you may be able
to resolve it on the first call, or with just some minor communication thereafter.
- Assuming the problem continues, request an itemized
bill from the doctor or hospital, and analyze every charge. There are often charges
on these bills for services not delivered. If you find any, notify the doctor
or hospital immediately to get the bill adjusted. Then, notify your insurer.
however, the denial has been legitimately issued. The insurance company may not
consider your medical procedure necessary, may consider it experimental or outside
their coverage area. That being the case, it's time to take additional steps.
- Request a formal review by the insurance company. The
customer service rep can tell you the specific procedures required. Then, state
your case for appeal in writing, and send the letter via certified mail with return
receipt requested. Make sure to do this immediately. Some companies have time
limits on when appeal requests can be filed. Don't wait.
the insurance company claims that the cost of your care was above their customary
cost, request the doctor's or surgeon's notes. They may show that there were mitigating
circumstances in your case that justify that cost. Also, request any other information
you need from your doctor to prove your case, and make sure you have it all in
State help is available
If you feel you're in over your head, if your appeal is denied or if your
plan does not respond in a timely fashion, contact your state's department of
insurance (in some states known as the department of managed care).
state has different ways of assisting consumers with health insurance appeals.
The Kaiser Family Foundation provides information on every
state's health care rules.
- Certain states mandate
certain types of coverage. Check the mandates for your state. The benefits you
seek may be mandated, even if they are not dictated specifically in your policy.
- Some states have an ombudsman who can provide
detailed guidance through the process. Some have special offices for HMO issues.
Some have only administrative assistance, taking the complaint and investigating.
Your state's department of insurance will be able to tell you exactly how much
assistance they can provide. Be sure to ask, and take advantage of all that is
- If you have been denied coverage due to
a perceived lack of medical necessity or because your insurance company considers
your coverage experimental or investigational, most states now allow you to apply
for an independent external review. Your state's department of insurance will
be able to inform you if your state is one of these. This review will allow for
an appeal of your case to an independent panel of physicians. While statistics
vary by state, you have about a 50-50 chance that the review board will find in
There is one notable exception to many of
the provisions stated here. If you work for a large employer, you may be covered
by a self-funded plan in which the employer is actually paying your claims and
merely using the insurance company for administrative purposes.
company's human resource department should be able to tell you if your plan is
self-funded. Self-funded plans are not subject to state regulation. Therefore,
if you need to appeal to a higher authority, you need to go to federal agencies,
Contact the Department of Labor's Pension and Welfare
Benefits Administration, and they will consider your appeal. Here, too, you have
a chance of winning on appeal, especially if they find that the decision in your
case was inconsistent with decisions made for other plan members.