Insurance Claim Denied? How to Fight Back

Receiving a denial letter from one's insurance carrier ranks high on the stress meter. I have begun covering this topic of how to fight an insurance denial in previous posts. However, let us revisit this topic in view of increased options and assistance now available online. This is good news for healthcare consumers, indeed.

Perhaps you have gotten an questionnaire from your insurer asking if you have other coverage. Let me first say that they need to know if you or your spouse has any other coverage so that they can properly coordinate your insurance coverages. (This is called Coordination of Benefits, or COB.) It does not matter which insurance plan is more inclusive or which one you think is primary or secondary. The rules are that the spouse whose BIRTHDAY occurs earlier in the year, has the primary plan. I know this seems dumb but it was just a way of cutting thru a mountain of other possible criteria that were open to dispute and differences of interpretation.

So the insurer has sent you a form asking if you/your spouse has other insurance. Perhaps this is not the first time that they have sent this form. It is possible that your returned form was lost or not entered into the system. It is equally possible that oh my, another year has flown by already and they just need to update their files.

However, if you are getting this form with a letter stating that they have not received a response to a prior request, and you know that you sent that in -- then you need to go into protective mode. Fill out the form as before, making sure it is legible; that means PRINT. Then mail it using the delivery confirmation service offered by the U.S. Postal Service. For less than a dollar, you will be assured that you can prove you sent in the requested information.

I recommend this over the other option, which is a signature delivery. The receiving party can refuse to sign it (this is especially true of vendors who are prone to legal action). Then you have wasted your money for the extra service, and are no further ahead.

Bear in mind that your denial letter may NOT be a final denial. It may merely ask for missing information that was not submitted with the original claim or was illegible. Sometimes it is not clear which member of the family is the patient! Calm down enough to read through this letter and zero in on the source of the problem. Often the diagnosis code was not submitted with the claim; you may have to call your physician's office to get that information. It is possible that your provider has gotten a copy of the same letter and has already responded to the request. So stay cool.

GETTING HELP WITH YOUR CLAIM DENIAL

There are now some online services that can carry the ball for you if you have had claims denied and you are getting nowhere with normal channels. Please take a moment to check these out and select one that offers specialized attention to your type of problem.

1) The Patient Advocate Foundation is online at PatientAdvocate.org. You may call toll free at 1-800-532-5274.

2) Advocacy for Patients with Chronic Illness is online at AdvocacyForPatients.org. Their phone number is 1-860-674-1370. This organization is directed by Jennifer C. Jaff, who advises you to keep a file and a record of how your doctor determined that you needed a given treatment. She claims a success rate (of appeals of insurance denials) of 80 percent, which is pretty impressive!

3)Most states (46) have procedures for independent review of denials. Connecticut is one. Many of those appeals are also successful. Contact the state insurance commissioner's office as a first step; directions for locating that are given below.

4)A lawyer -- if a lot of money is at stake -- and you may end up in court anyway for other reasons.

WHAT TO DO IF YOUR CLAIM IS DENIED

First, do NOT pay the bill. You are entitled to an explanation for the denial IN WRITING. The denial letter is sufficient for the insurer to meet that requirement; however, it may be a general form letter and not enlighten you regarding the specific problem. You will have to call their service line and hope to reach a real person.

Get out your copy of the insurance policy and try to locate the verbiage that applies to your claim. There should also be a section of the policy that explains your rights to dispute a denial of a claim. Follow that guideline, and mail your responses using Delivery Confirmation.

If there is missing information that you neglected to enter on a claim form, then just fill it in and re-submit. If it is a matter of a coding error or missing code, then that is something that your doctor's office has to take care of. NOTE: If this is a claim for medical supplies, you may be able to find codes posted on the website for the company that makes or provides your surgical supplies, wheelchair, colostomy supplies, etc.

Other, more complex reasons for a denial can include: You have a pre-existing condition. You have exceeded the lifetime benefit cap. You have changed employers, and need to update your coverage or inform then of the fact that you are utilizing your COBRA benefits option.

Usually the above reasons are not disputable, even though they are unjust. But it is possible that they may have made a mathematical error regarding your total healthcare bills thus far and you have in fact, NOT met the lifetime cap yet. This is something that you can then dispute with them.

Other reasons may also be worth disputing. Perhaps they are disallowing a claim because it was outside the network -- but there was no network facility or physician within a reasonable radius of your home. Perhaps a drug was not FDA-approved for your illness. Sometimes physicians use a drug for an off-label use, and this is a difficult item to dispute with your insurer. However, sometimes there is a similar drug that is made by a different manufacturer that IS covered under your plan. In that case, you may need to discuss with your doctor whether that other drug is appropriate to treat your condition.

Treatment may have been ruled as "unnecessary" "unproven" or "experimental". The thing I really hate about these terms is that the insurer is allowed to define what they mean. Is a treatment that has been commonly used for twenty years still considered BY THE INSURER as "experimental"? Then I think you have grounds to dispute this decision.

Fighting an insurance company often puts you in the position of trying to research medical issues online and look for articles in medical journals to prove that a given treatment has been shown to be effective. Frankly, most people have a hard time handling that. And it becomes a full-time job in addition to your regular job to continue the effort to win coverage or approval for treatment for yourself or a loved one.

So I recommend that you concentrate on taking care of your own life and hand over this dispute to another party. There are foundations and advocacy groups out there to help you, as well as the state insurance commissioner's office. (You can locate your state office by going to NAIC online, at NAIC.org. At the left end of the toolbar it says: States & Jurisdiction Map; click on that and a map of the USA and its territories appears. Find your state and click on that. Voila.)

Use this website and the many resources in my articles for help and tips on how to get your money's worth out of your health insurance. And good luck!