The US Department of Labor estimates that about 1 in 7 claims to employer health insurance plans are initially denied. A patient advocate says that she wins 80% of appeals. Yet only 4% of denials are appealed. These stats are taken from the AARP article The Health Claim Game. Are insurance companies relying on the “hassle factor” to help their bottom line? (…reminds me of The Incredibles and Insuricare)
Whether you think so or not, dealing with health insurance claims can be a nightmare. At the end of this article, a handy flowchart is provided which walks you through the “claim game”. Here’s the text:
To Make Insurers Pay
WHEN YOUR CLAIM IS DENIED…
1. Don’t pay the bill.
2. Get a reason for the denial in writing.
3. Review and follow your plan’s rules.
…Make the easy fixes…
• Missing information? Fill it in.
• Coding mistake? Have your doctor fix it.
…And assess other reasons for the denial.
Health care reformers want to end these exceptions, but for now they are hard to overcome:
• Preexisting condition
• Lifetime-benefit cap
• Change of employer, so coverage was delayed
These may be worth challenging:
• No network facility or physician was available
• Drug wasn’t FDA-approved for your illness
• Treatment was deemed unnecessary or unproven
WHEN PREPARING AN APPEAL…
1. Check the back of your denial notice to see how long you have to file—it’s usually 180 days.
2. Gather objective evidence of medical necessity, such as test results and prior failed treatments.
3. Gather journal articles showing the treatment is safe, effective.
4. File the request in writing (certified mail, return receipt).
IF YOU WANT HELP, SEEK OUT…
• A nonprofit patient advocate (your state’s insurance regulator or a disease association can suggest names)
• A lawyer if there’s a large sum of money at stake and you might end up in court.
IF YOUR INSURER STANDS FIRM, YOU CAN SEEK AN INDEPENDENT REVIEW…
If yours is a fully insured plan—that is, the insurer pays the claims. (Though insurers administer all kinds of health plans, roughly half are self-funded, meaning your employer pays the claims.) You have a fully insured policy if you buy insurance on your own.
To appeal a final rejection by a fully insured plan…
Go to your state insurance regulator.
To appeal a final rejection by a self-funded plan…
You will likely need to go to court, though your state insurance regulator can sometimes jawbone on your behalf.