Appealing a denied medical insurance claim: 10 steps
a healthy chance that one of your medical insurance claims will be denied or your reimbursement
will be whittled down to the point where you say "ouch."
The reasons for a denial vary from
a simple mistake -- your doctor's staff improperly coded the procedure
you had done, or you forgot to give your insurer your new address
-- to the complex, such as a medical procedure ruled "experimental"
and not covered. As health insurers tighten eligibility requirements,
and filing claims becomes more complicated, the odds of a denied
claim or reduced reimbursement have increased substantially.
Painful as it may be, there is
a remedy. While the procedure isn't exactly pleasant, it's likely
you can get the denial overturned with some luck and persistence.
When medical claims aren't settled between the consumer and the
insurer, appeals go to a state agency -- the medical field's version
of the U.S. Supreme Court.
According to a recent Henry J.
Kaiser Family Foundation report, insurers were overruled in about
half of such cases. The number of denials overturned varied by state,
from a high of 72 percent in Connecticut to a low of 21 percent
in Arizona and Minnesota. Most patient-advocacy organizations, involved
with helping consumers appeal denied claims, anecdotally report
that between 50 percent and 70 percent of disputes are resolved
through initial appeals made directly to health insurers.
to get the reimbursement, you have to be persistent. Here are some tips on how
to successfully appeal a medical claim that is denied.
Start by reading your medical policy. "The truth
is that many people don't read their plan documents and it comes back to hurt
them," says Betty Holm, a registered nurse with CareCounsel, a nationwide
patient advocacy firm based in San Rafael, Calif.
you don't have a copy lying around the house, many medical plans and corporations
will post policies online, says Michael Chee, a spokesman for Blue Cross of California.
"We offer members the ability to access their benefits and policies online
24 hours a day. You can print out what you need and take it to the doctor's office,"
Reading your medical policy will
help you know what's covered and what's not, as well as how to file
claims, so you can try to avoid
the appeal process in the first place. In addition, the policy
will also outline the appeal process, which may involve one or two
For example, most consumers will
first appeal to the medical insurer. Should that effort fail, consumers
can then take their case to a state regulatory agency. "What
you don't want to do is first go to the state and then to the insurer,"
Holm says. "You have to do it in the right order." In
addition, you need to note any deadlines for appealing.
2. Call member services.
If you can't find your policy or you've read it and still don't
understand how the appeal process works, call the member services
number for your health plan and get someone to walk you through
the process over the phone. Also ask for an explanation of the claim
denial. (The reasons will be listed on the claim denial form, but
it always helps to have someone translate the legalese into plain
English.) Determine if a phone appeal is possible as a first step.
More and more insurers are permitting first appeals to be done over
3. Get details from a phone
rep about information needed for appeal. "For
example, if additional information is needed, from whom should you
ask for it and what specifically should the provider of services
submit for your appeal," says Michelle Olef, who leads Hewitt's
Participant Advocacy Group. Your health insurer might want to see
your health history, an operative report, previous treatment plans,
or other details, she says.
4. Put it in writing. Once
you have a feel for the appeal process and an understanding of why
your claim was rejected, gather all your documentation (copies of
your policy, the rejected claim form, your medical bill, research
on your medical condition that documents that the treatment should
be covered, and so on). Prepare a letter that outlines your position
- that the denial should be overturned because you have proof that
the medical procedure is a medical necessity and not cosmetic or
whatever the denial says.
"Check everything that you
file with the insurance company because if the materials do not
support your case, you may just be wasting your right to fight the
issue," says Kevin Flynn, president of Healthcare Advocates
Inc., a nationwide consumer health advocacy organization based in
Philadelphia. Adds Holm, "The letter doesn't have to be lengthy
or beautiful prose, but a clear statement on why you are entitled
to the coverage and that it shouldn't be denied."