Fight a Denied Health Insurance Claim

Win and Learn how to appeal a decision

Laura Valentine, director of client services for CareCounsel, a patient advocacy company based in San Rafael, California. “When it comes to our own care, we don’t have a tendency to be as great of a consumer as we should be.”

If you or a family member have had a health insurance claim denied, you can and should appeal the decision. Read on for a step-by-step guide on how to effectively go through the appeals process and increase your chances of having a claim paid.

Health insurance claims can be denied for any number of reasons: “It could be a simple billing and coding error, or there could be a piece of information that needs to be submitted by the doctor,” says Erin Moaratty, quality assurance officer at the Patient Advocate Foundation. Based in Newport News, Virginia, the organization helps patients resolve insurance disputes. Typically, only services deemed medically necessary will be paid for, meaning claims for exploratory or cosmetic treatments are generally denied. What’s more, failing to follow insurance company procedures can lead to a denial. For example, if a plan requires pre-authorization for a certain surgery and you fail to get it, the insurer may not pay.

If a claim is denied, you first need to have a clear understanding of the rationale. As a policyholder, your insurance company will send you an Explanation of Benefits-a form that lists what the insurer paid for the claim, as well as any reasons the claim was denied. If you don’t receive a written explanation, call your insurance company. “I always recommend keeping a journal of what number you called, and get the name of who you spoke to,” says Daniel J. Tann, a Philadelphia-based attorney who has represented consumers in denied claims cases. “If they don’t give you a name, ask for an employee ID number.”

When the bills kept coming, both Samuel Jr. and his sister Denise Kirkland, 55, of New York City called HIP on their father’s behalf. The siblings also have a healthcare power of attorney in place-a legal document that authorizes them to make healthcare decisions for their father. Kirkland, a schoolteacher, made calls during her lunch break and on the way to her second job working with children with disabilities. “One department was telling me one thing, and another department was telling me something else, and nobody seemed to know what the other person was doing.” Finally, she and her brother learned that the problem centered around their father’s North Carolina hospital stay. HIP said Samuel Sr. should have come back to New York for treatment by doctors within its provider network, which frustrated Kirkland. “When someone gets sick away from home and is told they cannot travel, what are you supposed to do?”

The Coleys’ next step was to explain to the hospital why the bills weren’t being paid, a move that’s critical to protecting the patient’s credit rating. While you’re starting the appeals process, it’s important to keep the doctor’s office in the loop,

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