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Appealing a denied medical insurance claim: 10 steps

There's 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."

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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.

But to get the reimbursement, you have to be persistent. Here are some tips on how to successfully appeal a medical claim that is denied.

1. 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.

If 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," Chee says.

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 levels.

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 the phone.

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."

 

 
 
-- Posted: July 26, 2005
   

 

 
 

 

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