Updated on 06.17.13

Tactics for Appealing Health Insurance Denials

Trent Hamm

A few weeks ago, I put out a call on Twitter and on Facebook for detailed posts that people would like to see. I got enough great responses that I’m going to fill the entire month of July – one post per day – addressing these ideas.

Update: With the passage of the Affordable Care Act, there are improved options if you have been denied coverage — in addition to my suggestions below, review the post to see how you can obtain health insurance.

On Facebook, Elisabeth asked for information on “appealing health insurance denials of coverage.”

Health insurance companies don’t make money by paying for people’s medical bills (even though that’s why we hire them), so whenever there’s a case where they can see an easy way to deny it, they’ll do so. It makes sense for them as a business, even if it’s frustrating for us as people who need health care.

There’s a simple maxim to always follow when dealing with insurance companies, though: “the squeaky wheel gets the grease.” If it’s clear to them that you’re involved and have some idea of what you’re doing, you’re much more likely to get a resolution that you want.

Step 1: Know Your Situation
The first step is always to get all of your facts straight. You need to know some of the ins and outs of your health insurance plan as well as have thorough documentation of the care you received. Here are some questions to help you along that path.

+ What exactly is covered in your plan? What part of your plan matches up with the care you received?
+ Do you need a referral from your primary care physician for the type of care you received? Did you have that referral?
+ Is it required that the doctor you received care from be a member of the provider network covered by your policy?
+ Does your plan require prior authorization for the type of service you received? Did you get prior authorization from your insurance company (or did your doctor get it)?

Document all of these things with dates and as much information as you can gather. Have your facts straight before you even begin chasing down an appeal.

Step 2: Use Denials as a Clue, Not as a Stop Sign
If you’re denied, look for the reason for which the denial was issued. Your task is to cover that reason as clearly as possible – and you should acquire the needed information before you appeal. Depending on the reason for the denial, here are some steps you might want to take.

+ Ensure that your physician agrees that the procedure you were denied for was medically necessary, and get that in writing if at all possible.
+ If the insurer calls your procedure experimental, gather as much evidence in favor of it as you can.
+ If the insurer says that the procedure wasn’t explicitly covered, find evidence of similar procedures that are covered in your plan and ask your doctor for assistance in demonstrating the need for the procedure you had.

Step 3: Your Doctor Is Your Ally
A big theme you’ll see in the first two steps is that you’ll probably need some help from your doctor in this process, often in the form of documentation. Your doctor is going to be your ally here and you must keep that in mind through this process.

Be patient with your doctor. Don’t get angry with the doctor or the doctor’s staff. Do what you can to make it as easy as possible for them to help you with what you need. Honey works much better than vinegar in cases like this, so don’t give into your frustration and don’t get angry with your number one helper in this process (even if they seem uncooperative at times). The staff of many doctor’s offices are overburdened with requests, and one sure way to get your request overlooked is to act angry and self-righteous.

Step 4: Make an Appeal
Medical insurance companies have a formal appeals process which should be covered in your insurance documentation. Read through the documentation and understand it. It will be dry reading, I know, but the more you know about the process, the more likely it is that you’ll find success.

When you write your appeal, make all of the important details clear. Cover your health problems, particularly your full recent history with the problem in question. Discuss alternatives you’ve tried and exhausted. Mention what your physician recommended, particularly comments that counterbalance the reason your claim was denied. Outline why you were an ideal candidate for this procedure (which will probably take some research into the procedure). Discuss what will happen without the treatment.

You should also have supporting evidence. This is where research and time will come in handy. Quotes from your medical records are valuable. Direct quotes from your doctor are also valuable. Quotes from the insurance plan are incredibly valuable if they clearly support your case.

Provide as much documentation as you can for all of this evidence. Dates. Page numbers. Photocopies. You’re far better providing too much detail than not enough detail.

You should also keep a detailed log of all contact with the insurance company. Note what number you called, when you called it, who you spoke with, and what was discussed. You should also record all documentation you sent and when you sent it, as well as all mail you received from them. This may come in handy at a later time.

Most important, keep a full copy of every single piece of documentation that you send to the insurance company. Keep photocopies of the forms, of the records you sent them, and of every bit of your appeal. You may need these later on in the process. In fact, you should only be sending them copies of records and you should keep the originals for yourself.

Step 5: Get Free Assistance
Many states offer excellent help for people handling medical insurance denials through their state Department of Insurance. To find your state’s Department of Insurance, just use Google and type in “Department of Insurance” followed by your state.

Many states have a hotline you can call for assistance during this appeals process. Depending on the state, the information might be basic (providing simply information about the approximate timeline of the process) or it might be extensive (actually helping you with the appeal). They’re also equipped to handle any specific issues due to the state in which you reside.

In either case, it’s an assistance worth looking into if you find yourself in an appeal situation.

Another useful resource for insurance appeals is the Patient Advocate Foundation, which is another great resource for free assistance with medical appeals. You can simply fill out this form and assistance will contact you.

Step 6: Is a Lawyer Appropriate?
If your appeal is denied but you feel you’ve made a truly strong case, you may want to get legal help involved, particularly if the costs of the denial far outweigh the legal costs. Have a lawyer with experience in medical appeals review all of the documentation you’ve collected and determine if you have a case.

It is important to note that we all see our own situation through rose-colored glasses. A good lawyer will want to defend your rights and help you get the money you deserve, but if your case is weak, a good lawyer will say so. Remember, they’re financially ahead if they take on your case (particularly if they win), so if they’re telling you it’s not a good case, it probably isn’t.

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  1. Carrie says:

    I haven’t had to appeal or try to get something covered, but I do know that sometimes people have success getting something that is not listed as being covered at least partially paid. The instance I am thinking of are those who seek a home birth with a midwife. Most insurance companies don’t list this service as being covered, but if a midwife accepts insurance, it can be worked out as being covered.

    The point being, insisting about something can increase your chances of getting your claim covered, even if you are told no at first.

  2. AnnJo says:

    I don’t happen to share Trent’s prejudice that every business is in the business of screwing over its customers, but if you share that prejudice you might be happier with an insurance plan run by a non-profit. Regence/Blue Shield plans often are non-profits. I’ve had that coverage under individual plans for decades and have been happy with it (my car insurance is also through a non-profit for decades, with excellent experiences).

    That being said, I doubt if claims denials are all that different between profit and non-profit plans. I’m just saying you’ll FEEL better about it if you’re profit-phobic. Placebo effect.

  3. slccom says:

    Tape record the phone calls. Tell them that you are taping it, though.

    AnnJo, you are obviously basically healthy. Once you have claims exceeding a certain amount, the health insurance companies start denying almost everything. There is an absolutely irreconcilable conflict of interest between profits and paying claims, which is why no health insurer (or any other kind) should be for-profit. And the “non-profit” insurers have for-profit arms into which they funnel their excess income based on fraudulent denials.

    Insurance companies ARE in the business of screwing over their suckers, er, customers. And they have bought our lawmakers and the state insurance commissioners, who almost always move on to a cushy job with the companies they are supposed to be overseeing.

    If you ever get really sick, you’ll be experiencing the very same thing.

  4. AnnJo says:

    @slccom, you could say there’s an irreconcilable conflict of interest in EVERY commercial transaction, including however you earn your living, but it is balanced by the freedom of either side to walk away from the other and by the ability of our legal system to enforce contracts.

    Over the course of 38 years of having my individual health insurance plan, I’ve had three years of high claims, but never any denials. I also saw my parents go through years of extraordinarily high claims with very few minor denials, and a sibling go through years of cancer treatment (two different major types of cancer) with no denials. This may be because we purchased our policies from reputable insurers, bought the kind of policies we needed, and knew what they covered and didn’t cover.

    I’ve also been with the same car insurance company since 1977, and had two major and several smaller claims, all handled expeditiously and to my satisfaction. A few years back, I had a major claim against a rental property casualty insurer when a rental house was struck by lightning and suffered a major fire, and several smaller claims against homeowner policies, again all handled beautifully.

    In other words, in 40 years of adult life, I’ve had lots of opportunities to interact with insurance companies, and zero occasions to regret it. In fact, since I’m aware through my professional work of how often insurance claims are fraudulent or unfounded, I’m surprised at how very well I’ve been treated as a customer.

    You’ve obviously had some bad experiences, but you are stretching them to cover too much ground.

  5. slccom says:

    Congratulations, AnnJo. Our policies were from “reputable” insurers, too. Auto has been no problem; AllSnake refused to pay for a claim when our neighbors egged our house while we watched until I wrote to Corporate using InsuranceSpeak. Hartford dropped us because apparently I caused one too many roof-ruining hail storms.

    Blue Cross/Blue Screws of several incarnations lived up to their names. One friend had a newborn spend 10 days in NICU because of asthma. St. Louis Blue Screw didn’t pay a penny because “We don’t pay for well child care.” That guy went bankrupt. My husband tore some cartilage at age 30; it was a “pre-existing condition,” according to them. After all, he had had that knee for 30 years! It wasn’t until the surgeon, who happened to be the guy who operated on the St. Louis Cardinals and was the president of the AMA chapter informed them that no physician in St. Louis would accept their insurance if they didn’t pay the claim that they finally paid it. Another lady dropped a file cabinet drawer on her foot and broke it in July, half-way through the premium year. The same Blue Screw denied the claim as a “pre-existing condition.” Her husband had coverage with another company and paid the claim. They then informed Blue Screw that “We have as many lawyers as you do,” and they paid up.

    We sued one insurance company and got raped in court because they insured every court official in town. Transcripts are available. The details are really scary.

    You have been very, very, very lucky. Your people had cancer, which insurance companies actually believe in. Try getting chronic fatigue syndrome, or lyme disease, or something they don’t believe in. Try having MS with very expensive treatments that are “experimental.” Try having the plain language of the contract state that they will cover something and have them deny it just because they can, because they know you can’t afford to sue them.

    I hope your luck holds. Don’t count on it.

    Oh — not one of these claims were fraudulent. I know some people file such claims. I also know from my experience, and that of many more friends both personal and internet, that far more denials are fraudulent. They do it because they can.

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