Given the dollars at stake, correctly
appealing the denial of an insurance claim is a valuable skill, especially in
light of the figures we quoted last time about the high percentage of Medicare
Advantage claim denials that are overturned upon appeal. It does take a bit of your time to do it
right, but I think it’s worth it. You’ve
paid your premiums faithfully and on time; you deserve to get what you paid
for.
First, let me say that my own
experience comports with the figures I quoted about appeal outcomes. Whether appealing denial of coverage for a drug
or a procedure, I only failed once to get the initial adverse decision
reversed. And on that one occasion where
I failed, I was eventually reimbursed $1100 by the insurance company for the
claim because of a class action suit filed by another aggrieved party. Follow these guidelines and you will have a
better chance of success.
1. Denied
for provider being out of network.
This is one of the more common denials you are likely to encounter. Insurance companies contract with hospitals
and doctors to treat the people enrolled in their health plan(s). In exchange for the privilege of being an
in-network provider to whom the insurance company directs potential patients,
the providers agree to pre-negotiated rates for their services. That’s why you will see huge sums charged by
the provider but be amazed at how little they accept in the end for their
payment as they write off the rest. So
if you go outside the network of approved providers, you understand why the
insurance company is not going to cover the entire billed amount, and you end
up on the hook for much—or all—of the bill.
The best defense against this is to do your homework beforehand. Make sure before you enroll in an insurance
company’s plan that your doctors, the local hospital to which you are likely to
be admitted, and the nearest major medical center are all in network with the
plan. (And if you call the doctor’s
office to ask if they are in network, talk to the person there who files their
claims and ask, “Are you in network with XYZ Insurance”. Don’t ask if they “accept” the insurance; a
provider will bill most any insurance and “accept” whatever payment it sends. But whether it will cover your bill and not
leave you holding the bag for the balance is another matter. Phrase your question correctly.) You will also want to ensure there is a
robust and varied network of providers near your home, from physical therapists
to oncologists, because you never know when you will need their services and
you don’t want to have to travel an hour or more to get to a provider. But sometimes you need emergency care and don’t
have time to check whether the facility/doctor to which you are going (or being
taken) is in network. If this leads to a
denied claim, appeal on the basis of the circumstances—it was an emergency and
if life or limb were endangered if treatment was delayed, say so. A related “gotcha” from the insurance company
is when you have surgery or other treatment by an in network provider at an in
network facility, but then get a bill from a radiologist or anesthesiologist
that you didn’t know would be involved in your care and he is not in network,
leaving you with a rather large bill to pay on your own. This scenario is becoming less frequent as
patient advocacy groups and legislators fight back against it or even make laws
against the practice. If it still
happens to you, explain to the insurance company how you carefully picked in
network providers for your treatment but had no say in the choice of these
other caregivers, sometimes called “blind providers” (a term you can drop on
the insurance company to perhaps impress them that you know what you’re talking
about). Encourage the insurer to work
with the non-network provider (and vice versa) to come to terms so you are not
left with a bill, or at least not a very large one.
2. Denied
for not a covered service. Insurance
plans don’t automatically cover every conceivable medical procedure or drug. They have limits to their coverage like excluding
experimental therapies, limiting the number of treatments, putting age
restrictions on certain therapies, etc. Again, researching ahead of time will pay
dividends here. Make sure a planned
procedure is actually covered by the insurer.
Enlist the aid of the provider, if needed. If it appears that it will not be covered,
then talk with the provider to understand why the procedure is needed. If there is a valid clinical reason for the
therapy/test/procedure, then compose a letter or have the provider write a letter
to the insurer to explain the rationale for it.
A good example might be one in which I played a part, explaining to an insurer
that the family medical history of the insured justified waiving the age limit
they had imposed on a screening test.
The trick here is to imply or even flatly state that the insurer risks
incurring even steeper costs down the road if the insured does not get the
test, causing a medical condition to go undiagnosed and leading to expensive treatments
that the insurer will have to pay for later.
Of course, if you failed to do this homework first and had the procedure
done then received a denied claim, you will have to do all this retroactively, but
making the same arguments as above. It
might diminish your chances of success to be doing this after the fact, but it’s
not necessarily a lost cause. No harm in
trying.
I’ll offer some concluding
remarks on this subject in my next post.
Until then,
Roger
“The plans of the diligent
lead to profit, as surely as haste leads to poverty.” Proverbs 21:5
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