Claims to the contrary: Appealing a denied claim -- Page 2

5. Avoid emotional appeals. Putting your appeal in writing, even if you are initially talking to a customer service representative on the phone, will help you frame your arguments logically. Many people get angry and upset when a medical claim is denied. Getting emotional with a case worker will not improve your chances of winning your appeal and could hurt.

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Writing an appeal is much like "dealing with a mini lawsuit," says Flynn. A consumer has to organize his rebuttal in the same language and rules used by the health plan. "You can just say, 'It's my 5-year-old daughter's life at stake and I pay my premium so you should pay this bill.' That won't work," Flynn says. Instead play and win the game by the health plan rules.

6. Cover all the bases. For simple clerical errors, such as a wrongly coded medical procedure or an incorrectly noted medical plan identification number, you may be able to correct the information with a phone representative and get the claim resubmitted without doing an actual formal appeal.

If your case is less straightforward and requires more negotiation, also be sure to ask your insurance company if there are any state laws that would force the insurer to provide coverage, Flynn says. "Often, insurance companies forget that state laws apply in certain cases," he adds.

7. Track the details and stay organized. Make copies of all correspondence and request a written confirmation of any phone conversations with a representative from your health insurer. Have a notebook in which you keep notes of all conversations, whom you spoke to, what was said, what action you said you'd take, and what action the medical insurer representative said he or she would take.

After you speak to a customer service representative on the phone, follow up with a letter that outlines what was stated on the phone as well as any proposed action. Send all correspondence with a "confirmation receipt" so you can prove it was mailed and that your insurer received it. If the representative said over the phone that she would check into your claim and get back to you on the 15th of the month, put that in the summary you send the insurer. Keep a copy of that summary. Also, follow up. If the customer service rep doesn't call on the 15th, call her. Also note all deadlines to which you or your health insurer must adhere.

8. Enlist the help of professionals to make your case. "You want as much firepower as possible," Holm notes. Get your doctor involved and see if your employer has retained a health advocacy organization, such as CareCounsel, to help employees with medical claims.

If your company hasn't hired such a firm, see if your human resources personnel can help or consider hiring a patient advocacy firm yourself. Some organizations, such as Hewitt's Participant Advocacy Group, only work through employers, but some smaller firms will take on individual clients. Fees can range from $50 to $500, depending on the firm, the amount of money at stake, and the complexity of your case.

Also seek the aid of any nonprofits involved with the treatment of your or your loved one's disease. For example, the National Multiple Sclerosis Society can help make the case about whether a treatment is standard or experimental for that particular disease. In addition, many associations have discussion boards where members can exchange tips about getting medical coverage or getting denials of coverage overturned.

9. Do your own research. This approach helps when a health insurance provider fails to reimburse you totally for a medical procedure because the amount charged was deemed "above average" for your area. Call up other doctors in your area and find out how much they would charge. If your doctor turns out to be the cheapest, document that fact and try haggling with the medical insurer to get more of the amount covered. This won't always work, but it's worth a try. (And before your next procedure, you might want to shop around and then check with your insurer to see what it considers the "going rate" for that procedure in preparation for the next claim.)

10. Go to a higher authority. After you've exhausted all internal appeals with the medical insurer, the next step is to go to your state's regulatory agency that oversees insurance. For some states, it may be an agency that supervises "managed health care." You can find the appropriate agency on your state's Web site or ask your medical insurer. By law, medical insurance companies must explain how you can appeal your denied claim to the state.

Many states -- at last count 41 plus the District of Columbia, according to the Kaiser Family Foundation -- have set up independent medical review boards to hear appeals. These review boards consist of physicians who review individual cases and insurance policies to determine what coverage should have been received.

Once you reach the state level, many of the same rules apply as when you appeal to your health insurer: Keep good records; do your homework; be persistent.

If at any time you feel overwhelmed by the process, consider hiring a patient-advocacy firm to help. It can be well worth the expense. For example, Healthcare Advocates cited the case of an insurer denying a $120,000 medical bill to treat a daughter's anorexia. The father ended up using his children's college funds to pay the freight. He then hired Healthcare Advocates for $500 and the patient advocacy organization obtained $100,000 in reimbursement for the family.

Holm recently worked on a case where a young woman diagnosed with leukemia needed multiple blood transfusions. She had coverage through her father's medical plan. Although the blood products weren't covered in 2004 by the plan, the plan was changed in 2005 to include such transfusions. So Holm helped the mother, who was handling her daughter's medical claim, fight the denial. Eventually the medical plan reversed its denial and reimbursed $26,000 to the family.

While denial of benefits can be difficult to understand and fight, persistence can certainly pay off.