Fight a Denied Health Insurance Claim

Win and Learn how to appeal a decision

and ask if the account can be put on hold while the process runs its course, advises CareCounsel’s Valentine. While it’s up to their discretion to do so, many healthcare providers are willing to work with patients appealing a denied claim.

When Samuel Jr. explained his father’s situation, the billing department not only agreed to wait out the appeal, they also brought a resource to the family’s attention that would turn out to be critical: a patient advocate to help them make their appeal.

NAVIGATING THE PROCESS
Samuel Jr. was relieved to learn that consumers don’t have to battle insurers alone. Some patient advocate organizations, such as the Patient Advocate Foundation, offer free assistance. Others charge a fee, typically based on the length and complexity of the case. For example, Philadelphia-based HealthCare Advocates Inc. charges $50 for a month of assistance and $300 for a year on top of a $19.95 annual membership fee. “We work with the insurance company to get the claim paid for you,” says President Kevin Flynn. “We know the laws, we know the loopholes, we know how to get around them.” If your health insurance comes through your employer, check with human resources to see if you can take advantage of an employer-sponsored advocate such as CareCounsel.

Whether or not you use an advocate, the next step is to review your insurer’s appeals process and follow it to the letter. Because every insurance company has different procedures, it’s important to pay particular attention to the amount of time you have to appeal, says Moaratty. “A lot of times it’s a 60-day window [from the date on the denial letter], but it does vary. Depending on the insurance carrier, if you’ve bypassed that, you’ve basically exhausted your efforts and you can’t go further.”

The crux of an appeal is a letter stating why the claim should be paid, as well as p
roviding any documentation that proves that the procedure was medically necessary. Your doctor can help you strengthen your case with the appropriate paperwork. In Samuel Sr.’s case, “We had to prove that the doctors were correct in admitting him and providing the services that they did,” says Margie Griffin, a senior case manager for the Patient Advocate Foundation. “We wrote up the appeal letter pointing out the major facts in the doctor’s medical notes.” Any other information about the disputed procedure, such as medical studies, can be included as well. Once all the materials have been gathered, send them to the insurer using a delivery service, such as certified mail, that confirms delivery.

The insurance company will make a decision, generally within a couple of months; though decisions can be expedited in urgent care cases. If the denial is reversed, the insurer agrees to pay the claim, but even if the denial stands, you still have options. Many insurers allow up to three appeals so if you lose the first one, you can try to make your case again. But do more research so that you can make a stronger

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