Fight a Denied Health Insurance Claim

Win and Learn how to appeal a decision

case for medical necessity. For example, a new medical study may sway the decision.

If your insurer’s appeal process does not yield favorable results, you may be able to appeal its decision to your state’s external review program. In such cases, an independent company or board made up of medical professionals will review the case. Programs vary from state to state; in some states, the appeal is strictly done by filing paperwork, while in others, you may be called to speak with the independent reviewer. The Kaiser Family Foundation provides information about each state’s external appeals process at www.kff.org/consumerguide/states.cfm.

The Coleys won their case after the first appeal by proving that their patriarch needed to be treated in North Carolina and couldn’t have waited until he got back to New York. Last November-eight months after Samuel Sr. was admitted to the hospital-the family received a letter from HIP agreeing to pay the bills. By January, most of the bills had been paid. Though HIP’s initial denial was overturned, the insurer believes the appeals process is fair. Unable to comment on the Coleys’ case because of privacy regulations, Ilene Margolin, senior vice president with the company, says, “Many times we are appealed and other times we’re not-we totally support this process.” Coley Sr. has since changed insurance providers and relocated to North Carolina to live with his son. His wife, Mollie, is in a nearby nursing home in Raleigh.

Samuel Jr. says the experience has left him wiser and much more attentive to any paperwork he receives that’s related to his healthcare and that of his family. “There are a lot of changes with insurance companies and their coverage,” he says. “It’s important for us to be savvy.”

Reduce Your Chances of Getting Denied
While it’s impossible to eliminate all risk of having a health insurance claim denied, there are steps you can take to lower your chances.

Know what’s covered. Your health insurance company should provide you with a description of your coverage. Take the time to read through it to see if there are certain procedures you must follow, such as contacting the insurer within 24 hours of an emergency room visit. “Sometimes patients don’t know their plan language-what’s covered and what’s not covered,” says Carolyn Andrews, director of the Patient Advocate Foundation’s National African American Outreach Program. But that’s a mistake because that plan agreement is like a contract between the patient and the insurance company, Andrews adds.

Check for changes. Health insurance plans can change from year to year. Don’t assume upon renewing your policy that everything’s the same as the year before. Also make sure your doctor is still a member of your insurance provider’s network, because insurers can refuse payment for procedures performed out of network. Don’t assume that just because your doctor was in the network in December he or she is going to be in the same network the following year.

Get pre-authorizations. Any time a doctor orders laboratory work or a special test, make sure your insurer has no

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