Health insurance claim denied? Fight back, possibly win by filing appeal: Here’s how – cleveland.com

CLEVELAND, Ohio — It’s bad news when your health insurance refuses to pay a claim for a medication, hospital stay or treatment. But don’t automatically assume you’re stuck with the bill.

Patients can appeal. In many instances, the consumer wins.

“People should know that every time they’re denied anything, they have a right to appeal it,” said Craig Thomas, senior director of clinical services of the Western Reserve Area Agency on Aging.

The appeals process covers claims denied by private and employer-sponsored insurance, as well as Medicare, Medicaid, and managed care plans.

The appeals process takes time, effort and patience. But about 40% of first-round appeals reverse the health insurance’ companies decision, said Caitlin Donovan, senior director with the Patient Advocate Foundation, a national nonprofit that helps patients with chronic and life-threatening illness.

“It’s really worth it to go through the process,” Donovan said.

Disputes are not unusual. Health insurance providers on the healthcare.gov Affordable Care Act Marketplace denied an average of 1-in-5 in-network health insurance claims, according to a 2019 report by the Kaiser Family Foundation, a nonprofit organization focused on national health issues.

Here’s some key information about the appeal process, drawn from interviews with Donovan and Thomas, information from the National Association of Insurance Commissioners, healthcare.gov, and insure.com, and reporting by msn.com and WFAE-FM.

Know your rights

Tell you insurer you want to file an internal appeal, which can take up to 30 days.

If the first appeal is turned down, the second step is an external review, which sends the dispute to an independent third party for review. It can take up to 90 days to be resolved.

An expedited appeal is used by patients needing urgent medical care; decisions are made within 72 hours. For instance, if a hospitalized patient is told that their hospital stay must end under Medicare rules, that person can appeal and be allowed to stay in the hospital while awaiting a decision.

Pay attention to deadlines

If an insurance company denies a claim, it must send notification to the patient in a snail mail letter giving the reason for the denial, and how to appeal.

As soon as a claim is denied, the clock starts ticking on the deadline for filing an appeal, Thomas said. It’s smart to open surface mail promptly if you think a letter regarding medical bills might be coming.

Otherwise, “by the time (a patient) looks at it, the time has elapsed and they can’t do anything. They have missed that appeal opportunity,” Thomas said.

Start an internal appeal

Ask your health insurance company how to file an internal appeal by calling the customer service number provided on your insurance card.

If your employer has a self-insured plan, ask human resources to talk to the insurance company to find a resolution. Patients may not know if their plan is self-insured or just employer-sponsored, but many big corporations — such as Amazon and Walmart — have self-insured plans, Donovan said. In a traditional appeal for an employer-sponsored plan, human resources wouldn’t necessarily get involved.

Or, ask your healthcare provider if it will take care of the appeal for you.

Review your policy to find out whether coverage includes the treatment, procedure, type of office visit or service that was denied. Also review the explanation of benefits sent for every service and treatment received, including the billing code.

Doublecheck facts with a phone call

Call your healthcare provider’s billing office to make sure there are no typos in the claim paperwork, all information is correct and that the claim was sent to your current insurance company. If there is an error, the billing office can resubmit your claim to the insurer without going through the formal appeals process.

Take notes on every phone conversation, including the name of who you spoke with, the date and time, and the call reference number.

Appealing a health insurance claim denial can be frustrating, but it’s worth the effort, especially for recurring expenses.

Gather relevant documents

Put together a documentation packet that includes supporting documents to send in with your appeal. This can include medical journal articles, a second medical opinion, and a letter from the doctor you treated you.

Write a letter summarizing what’s in your packet, and explaining why your claim should be paid. If the denial was regarding a prescription drug, describe the benefits you’ve received from that medication.

When writing an appeal letter, don’t tell an emotional story or vent your anger on the page. “That’s not how the system works,” Donovan said.

Send the paperwork via certified mail so you have proof it was received.

Still told no? Ask for external review

If a claim is still denied after an internal appeal, patients can request an external review performed by an independent review organization.

Patients must ask for an external appeal within a specific amount of time after receiving the internal appeal decision.

Look for information on how to request an external review on the internal appeals notice sent to you.

New information can be submitted to support your position.

‘Not medically necessary:’ reasons why claims are denied

Here are some common reasons why health insurance companies turn down claims:

* A patient saw a physician or went to a facility that wasn’t in their health plan’s network.

* The doctor didn’t get the necessary prior authorization for a medical service.

* The health plan doesn’t cover the procedure, test, drug or service.

* The healthcare provider didn’t submit the correct claims information to the insurance company, such as the wrong billing code.

* The treatment was not considered medically necessary.

How to find more help

Ask if there’s another appeal that you’re eligible for.

Appoint a spouse, child or close friend to help with the appeals process, keep track of paperwork and speak on the patient’s behalf.

The Alliance of Claims Assistance Professionals helps patients find a medical billing advocate who provides fee-based assistance with insurance company appeals and other medical billing issues.

Medicare Parts A and B appeals process.

Medicare Part D appeals process explained.

Medicaid: Information on appeals and hearings.

The Ohio Department of Insurance: On-line toolkit to help consumers and medical providers understand the appeals process.

The Patient Advocate Foundation: Online course on how to appeal a health insurance denial.

Sample letters for appealing a claim denial.

The Western Reserve Area Agency on Aging: Serves seniors in Cuyahoga, Geauga, Lake, Lorain and Medina counties; explains different healthcare insurance programs (Medicare, Medicaid, Managed Care), helps healthcare claims and appeals, and more.