Odds favor appealing a claim denial


Most of us become quite complacent with regard to our health insurers.

We have done our homework, chosen a plan, and are confident when we hand the card over to the receptionist that all will be covered (minus the co-pay, perhaps).

It often comes as quite a surprise to receive a letter of denial for a procedure, test or treatment that you were told would be beneficial or preventive. What do you do when your health insurance company says "no"?

First, understand exactly why the company denied your claim. Is it clearly spelled out in your policy that this is a treatment or procedure that is routinely not covered? Is it considered experimental? If the test or treatment hasn't been approved by the U.S. Food and Drug Administration, the health insurer probably won't change its decision.

Do your homework when preparing to file an appeal. Are you asking for something that is considered a standard practice for treatment? Medical and disease-specific Web sites list practice or treatment guidelines. Cite as much research as possible in your appeal letter and also include facts about the case including test results, second opinions and doctor's summaries.

From the first contact with the insurer keep meticulous notes, including the name of the person you speak to, date and time of the call and a summary of the conversation. Often you can request a "case manager" who will be assigned to you for the duration of the process.

Having a relationship with one person saves the need to keep repeating the story. Obtain the procedure for filing an appeal and follow it perfectly. Missing deadlines or not providing complete information can be cause for a final denial.

Enlist the help of your doctor. Often there is a staff person in the practice whose area of expertise is writing appeal letters. It will help if your doctor writes a letter of medical necessity. This generally means that without the care in question your condition would, in all probability, get worse.

It may seem daunting to go up against your health insurer, especially since you are probably not feeling well and perhaps are dealing with a serious diagnosis. Admittedly it will take some work and a lot of persistence. But according to Dr. Michael Roizen and Mehmet Oz, authors of You, The Smart Patient, studies show that patients who appealed denied insurance claims were successful in far more than half of the cases.

Use the following health organizing tips to guide you when your health insurer says "no":

Before calling the insurance company, have the following in front of you: the patient's date of birth, health insurance card, the denial letter and a list of questions and points you want to make.

Immediately ask for the person's name and ascertain if this is the person who will be handling the call before you go through the whole story.

Follow up your call with a letter summarizing all the facts of the case. Be sure to say you are initiating an appeal. Send the letter via traceable mail, such as certified or registered, and keep copies of everything you send.

Note the time frame within which they have to make a decision. If you feel your health is in jeopardy, you may ask for an expedited appeal.

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