2008 Insurance Guide
insurance
Fighting health insurance claim denials

One of these days, you might have to battle your health insurance company over a denial of coverage.

Of 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 coverage.

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 information.

Some experts feel that legislation is tilting the regulatory environment in the patients' favor.

"The 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.

Here 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.
  • Take 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! The importance of 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 company immediately.

 

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