Dealing with health insurance denials is often a difficult and frustrating process. It usually comes at a time when you are experiencing some stress already due to a medical illness and the last thing you need is to be forced to deal with an insurance denial. Fortunately, there are some places where you can get free assistance. This article will attempt to provide some general guidance. However, each situation is going to be different. In many cases, with the right information and approach, you can be successful in obtaining the benefits to which you are entitled. To a large extent, it will also depend on the terms and conditions of your health insurance policy. Below are some tips and suggestions about how to deal with this problem.
Gather information about your denial.
It is important to have all of the necessary information you will need for your appeal in one place. Initially, you will need a copy of your denial letter. This should be sent to you by the insurance company and should clearly explain the specific reason(s) for the denial. If you do not have the letter or do not understand it, call the insurance company immediately. If your insurance company requires pre-authorization of treatment, you will need to find out what, if anything, the doctor or hospital did to request pre-authorization. You should obtain copies of this information in writing.
You should also obtain a copy of the insurance plan document and plan summary. This information will form the basis of the contract between you and the insurance company. It is important to have these documents and review them to learn about your benefits, appeal rights and procedures. If you do not have this information, the insurance company must provide them to you within thirty days of your written request.
It will be very helpful for you to have a complete copy of your medical records prior to starting your appeal. If the company is denying your care based upon a pre-existing condition, you will need to have the specific records on which they are basing their decision. You may also have other records, which they may not have, which could indicate that the pre-existing condition had resolved and therefore would not be grounds for their denial. Try to keep all of your medical records in one place and if possible sorted by doctor or facility.
Ask your doctor and his staff to help with your appeal.
It is important to get a letter from your treating doctor or specialist to submit to the insurance company as part of your appeal. The letter should address the specific reasons for your denial. You should give your doctor a copy of your denial letter as soon as possible. The letter from your doctor should provide information about your illness that your doctor feels is clinically important. It should also provide a specific treatment plan and a detailed description of why the treatment is medically necessary.
On occasion, your claim may be denied if the insurance company does not believe that the proposed treatment is going to be helpful or if it is experimental. If so, it may be helpful to ask your doctor to provide copies of articles explaining why the procedure may be helpful or that it has had good results in other patients. Some doctors will be more understanding of the need for this information than others, but it never hurts to ask for it. The internet may also be a good source of information to include with your appeal.
Be persistent: Appeal again and again and again.
Your appeal should be in writing and normally sent registered mail. That will allow you to make sure that the insurance company did in fact get your letter. You should always keep a copy of everything you send to your insurance company. You may also want to contact them after three to four days to make sure they got your letter and determine how long they expect the appeal process to take.
Your insurance policy may provide for several levels of appeal or review. In most cases, the second appeal will be decided by a different person than the one who made the initial denial. Therefore you should not give up after the first denial. It may also be possible to get additional information to submit, perhaps from another doctor. You should also review the denial letter as well as the doctor’s initial letter to make sure that it addresses the specific reasons for your denial. You should also make sure that it does not contain words that may trigger a denial or not be covered by your policy. Some examples might be: “elective”, “pre-existing”, “cosmetic”, “palliative”. If these are grounds for the denial, they should be listed in the denial letter, and your appeal should address why your treatment is different.
It may be helpful to speak with someone by phone prior to submitting your second appeal. Ask specifically what type of information would be considered and what process will be used to re-evaluate your claim. Make sure that you have written down the name and contact information of everyone you speak with at the insurance company. It may also be helpful to speak with a supervisor if you are not able to get through to the claims adjuster or if they do not return you calls promptly.
Consult a lawyer.
When to contact a lawyer, whom to contact and how much will it cost are all important questions you will need to address if your claim continues to be denied. It is also important to have all of your information readily available for the lawyer to review once you do contact someone for help. If you are able to get a free consultation, it might be helpful to consult a lawyer prior to beginning your appeal. If not, you may want to consider putting together an appeal package and setting up a brief consultation for someone to review your package. It should not cost more than $150-$250 for a consultation. Depending on the extent of the treatment being requested or denied, it may be worthwhile to do so.
It is often difficult to know which lawyer to consult with. The phone book may provide the names of lawyers; however, having a personal referral will generally provide you with more information about the lawyer than what would be available in the phone book or other ads. You should not hesitate to ask the lawyer or his/her staff about their qualifications to handle your type of claim, how much it will cost, and how they will keep your informed about the progress of your case. Additional information about how to choose a lawyer can be found on this website under the “Consumer Guides” tab.
Where to find additional help.
There are several excellent sources of information about insurance denials. You may also be able to get some specific help from a non-profit organization, The Patient Advocate Foundation. They can be reached through their website at https://www.patientadvocate.org)/ or by calling 800-532-5274.
You may also want to contact the Colorado Insurance Commission at https://www.dora.state.co.us/ or by calling 800-894-7490. They will probably ask you to file a complaint, which may be useful in getting the insurance company to respond.
Although the nature of our law practice does not generally involve health insurance claim denials, we are happy to consult with you about your denial and offer suggestions about how you may want to handle your situation.