A couple of years ago I saw a rheumatologist for a problem that developed in my fingers. After obtaining my history and performing a thorough physical examination, the specialist ordered 32 blood tests in an attempt to determine the cause of my problem. A month later I received a bill from the lab for $985. I logged on to my health insurance company’s website and reviewed my Explanation of Benefits (EOB) statement. (An EOB is a document from the insurance company that describes how a medical claim was processed and what the patient owes.) I was surprised to see that several of the tests were denied. A few of the tests were deemed “not medically necessary” by my insurance company. The most expensive of the tests ($494), was deemed “experimental” and was also denied.
As a patient, I was frustrated that a single blood test could cost almost $500 and that I received such a large bill for lab work. As a physician, I was angry that a person without a medical degree determined that tests ordered by my physician were “unnecessary” and “experimental”. I contacted my insurance company and was unable to resolve the issue, so I filed a written appeal.
Before deciding to appeal an insurance denial, it is very important that you review your policy. Your health insurance policy is a contract between you and the insurance company. It delineates what is covered, as well as your rights and responsibilities. Many individuals gloss over this information or don’t bother to read the policy at all, but the details are very important.
There are several reasons an insurance company may deny a claim:
- The service is not covered by your plan.
- The service is deemed “not medically necessary”.
- The service is deemed experimental or investigational.
- The procedure or test requires pre-authorization.
- Many insurance companies require that the physician or hospital obtain approval PRIOR to certain procedures, such as MRI scans or surgical procedures.
- Another insurance company is responsible for the claim.
- If the medical care you received was the result of an automobile accident, an accident at work, or if you have a second health insurance company, another policy may be responsible for payment.
- The care was provided by an out-of-network provider.
- This generally applies to individuals with HMO (Health Maintenance Organization) coverage.
- There is an error with the claim.
- Occasionally, simple clerical errors (like incorrect billing codes or the wrong date of birth) will cause a claim to be denied.
How to file an appeal:
- Be sure you have a clear understanding of the reason for the denial.
The insurance company is obligated to provide the reason(s) for denial. Review your EOB (Explanation of Benefits) statement, available on the company’s website. Next to each denied service there will typically be a numeric code. A legend explaining each code will appear at the end of the document. It is also a good idea to call the insurance company and speak to a representative for a full explanation.
- Review your insurance policy to ensure the reasons for denial are valid.
Focus on covered services and whether there are requirements for pre-authorization.
- Review the insurance company’s process for filing appeals.
Make sure you follow all of the instructions and make note of the deadlines to file.
- Gather the information you will need to state your case.
Jot down notes regarding your illness, doctor visits, medications, and prior tests/procedures/treatment. If previous (approved) therapies have been unsuccessful at treating your condition, this will be important to document. Request a copy of the guidelines the insurance company uses to determine medical necessity.
- Write an appeal letter.
The purpose of your appeal letter is to convince the insurance company to cover the service(s) in question. Provide a brief description of your medical condition, how it impacts your life, and why the proposed medical service is necessary. Provide evidence that your policy covers the service using language from written materials provided by the company or from their website. Consider enlisting the help of your physician to determine if there is medical literature to support the necessity of the service and, if so, be sure to include this information in your letter. (In some cases, the physician will write the appeal letter on your behalf.) Include contact information for you and your physician. Be concise and polite. Send the letter via certified mail.
- Take meticulous notes.
Take notes during every conversation you have with the insurance company. Write down the date of the call, the name of the person with whom you spoke, and a summary of the conversation. Make note of the timeline provided and set a reminder to call for status updates.
- Escalate if necessary.
When discussing your case with the insurance company, always ask to speak to the supervisor if you are not getting the information you need. If you are having difficulty navigating the appeals process on your own, you may be able to get assistance from a third party. Many states offer help with health insurance appeals through Consumer Assistance Programs (CAPs). A quick internet search will provide you with the contact information for your state’s program.
If the insurance company upholds the denial decision after your appeal, you may have the right to request an external review. Consult your insurance company’s policies for more information.
Approximately four weeks after I filed my appeal, my insurance company notified me that they would cover all but one of the laboratory studies. They upheld their decision that the $494 test was experimental so I was responsible for paying those charges. While it was not the outcome I hoped for, I was successful in reducing my out-of-pocket expenses and I felt good about advocating for myself.
Take some time to review your health insurance policy to ensure you know what services are covered. If you feel a medical service is wrongfully denied, consider following these steps to file an appeal. It will be worth your time and effort, especially if the outcome is in your favor.
Are you dealing with an insurance denial? Have you been successful with an appeal? Please leave a comment below. We’d love to hear from you.
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