Don't Take No For An Answer

By Chelle Cordero

November 4, 2011 5 min read

You faced your fears, went to the doctor, followed all the treatments and took all of the pills -- and now you're feeling better. But when the bills start to trickle in, your insurance company denies coverage. Suddenly, you're feeling sick again.

While suffering an illness can fill you with angst, facing the high cost of medical treatments, doctor bills and hospitalizations can be staggering. It's reassuring to have health insurance; you expect the basics, after co-pays, to be covered. But what if they're not? What kind of recourse do you have when your insurance company says no?

In order to maximize insurance benefits, read through your policy and follow the plan language; explore discount drug options with large retailers, supermarkets, or pharmacy chains; and discuss drug replacement programs with the physician. Become familiar with any pre-authorizations that may be necessary, and make sure you get the appropriate referrals.

Many plans will permit you to notify your doctor after seeking emergency care, but non-emergency procedures require doctor approval first. Do your research about in-plan doctors and providers and determine whether you have any provisions for out-of-plan services. Be aware of required waiting periods for pre-existing conditions.

According to the Patient Advocate Foundation, "A non-covered service or insurance denial can result from a pre-existing benefit exclusion or pre-authorization issue such as previous medical advice or treatment before the effective date of the health insurance plan." If this happens to you, you should carefully review the specific reason for denial and see whether you have other coverage options through personal or alternatively sponsored plans (i.e., employer or spousal coverage). Speak to the doctor's office, hospital advocacy or case manager to find out whether they are willing to intercede in your behalf.

"Sometimes it's just a matter of reprocessing the claim," says Erin Moaratty, chief of external communications for the Patient Advocate Foundation.

If you're denied coverage, read the determination letter carefully for the exact reason that you've been turned down. Sometimes the answer is as simple as a clerical error, your doctor's office listing the wrong code or missing documentation. Billing issues, duplicate claims and absent information can trigger a denial. Contact your insurance company directly for the proper procedure to follow to rectify an error. If the desired procedure is to be scheduled for the future and you're looking to pre-certify, you may need an affirmation from your doctor that proves it's a necessary treatment and not just an elective or cosmetic procedure.

If you need to file a formal appeal, make sure that you have all of your information and records handy. Be prepared to answer what type of service was, or is, needed. What was the reason the insurance company gave for denying coverage? What is the anticipated cost? Is the procedure past any pre-existing waiting periods? Is pre-authorization required or were pre-authorization procedures followed? According to a March 2011 report by the U.S. Government Accountability Office, 39 to 59 percent of denied claims were overturned after appeal. Your appeal has to be factual, informed, firm and polite.

The first step is to appeal to your insurance company, so find out the proper contact address for the appeals department. Don't delay filing your appeal, as the insurance company will take into account the length of time it takes for you to respond. Always make your appeal in writing and mail it with a return receipt so that you have proof it was submitted.

Include letters from your attending physician, medical records, any written care instructions you might have received from a hospital, and evidence that supports taking medications or specific treatments. If you don't hear from the company, follow up politely; you need them to listen to you. If the claim is still denied, contact the medical director in the company with your complete documentation.

If you're unsuccessful after taking these first steps, consider contacting your state's insurance oversight department. If you're at a loss or confused as to how to proceed, a nonprofit organization such as the Patient Advocate Foundation offers advice for free. Fee-based companies may also help negotiate lower fees for uncovered services.

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