Four Steps to Fight a Claim Denial Do you figure the hassle of battling a denial isn't worth it? Think again! According to a recent report from the Government Accountability Office (GAO), patients who appeal denials directly to the insurer win 39% to 59% of the time. What's more, the Obama Administration's healthcare reform law requires most insurance plans to let you make an external appeal, in which a 3rd party rules on the case if a direct appeal fails. (Previously many insured patients had no such recourse). To increase your chances of winning an appeal, consider these steps. 1. Check for Errors.
According to the American Medical Association, 19% of claims' payments have errors. Lots of doctors and hospitals bills do, too. For example, there is a code for a check up for a 1-4 year old, but if your child is 6, the claim will be denied.
If the letter doesn't explain the reason for the denial, call member services and ask for more information, including asking for what codes were used. Check them with your healthcare provider's office to make sure they're accurate. If not, ask the office to correct the claim and resubmit it.
2. Make Your Case In Writing. Other explanations for denials are that the care wasn't medically necessary or was experimental or investigational or that you didn't get pre-authorization. In such cases, you usually have to file an appeal within 180 days. When making such a formal appeal, include: - A cover letter summarizing your argument and what's in your appeals packet
- A letter from your doctor explaining your diagnosis and symptoms, what other treatments you've tried, and what would have happened had you not gotten treatment.
- Copies of your medical records back to the date of your diagnosis.
- In the case of experimental or investigational denials, include studies published in medical journals that have found the treatment to be effective for patients in your situation (ask your provider's office for help with this).
- Mail the entire packet, with delivery confirmation, to the insurance company. And please don't forget to copy the packet before you send it. That way you'll have a record of it.
3. Escalate The Battle.
If your insurance company won't budge, make an appeal to an independent review organization that has the power to overturn your insurer's decision. Your legal rights and the procedures to follow vary by state and by health plan so do some homework. When insurer's deny an appeal, they sometimes rely on what's called a clinical peer review. Don't be afraid to ask for a copy of the review to check the qualifications of the person who performed it. For instance, If the case involves your elderly parent and a pediatrician did the review, you might consider challenging the credibility of the reviewer to render a decision. Update your information packet to counter your insurer's argument, then file it. If your case is deemed urgent, you'll get a ruling within 72 hours; if not urgent, it may take up to 45 days. 4. Bring in A Pro When the stakes are high, like thousands of dollars, and you're in a time crunch, consider hiring or enlisting the help of a patient advocate. We at Guardian Nurses often get involved with cases where patients are appealing to their insurance company (like the one we highlighted in last month's issue of The Flame. Sometimes when you're so close to an issue, it's hard to be objective. Having a third party help out can often be more efficient and more effective. | 
