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Questioning Your Insurer's Decisions

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Believe it or not, health care insurance companies do not always have the final word on the kind of treatment you receive or whether they will pay for it. It’s possible to challenge a decision and win. Unfortunately, most patients fail to take advantage of their appeal rights, and many pay bills they don’t have to. The biggest problem for consumers is the time and energy it takes to file complaints. But many times it’s worth it.

Many health insurance companies have found it simply isn’t worth their time to fight in borderline cases. Although their rules may seem strict, insurers often find it’s more cost effective to grant a patient’s request than waste money fighting it. But battling health-plan providers means you need to know how to navigate the red tape. Here are some things you should know:

  • By law, an insurer must notify you in writing of a claim denial within 30 days after a claim is filed for medical services you’ve already gotten, and within 72 hours for urgent care cases.
  • In most cases, the denial must give you details about the reasons for the denial of claims or coverage, as well as information on how to start the appeals process.

Before you appeal, you may want to take these steps:

  •  Ask your insurance company’s customer service representative for a full explanation of why the claim was denied.
  • Review your health insurance plan’s benefits. This may require looking at the more detailed Summary of Benefits notice.
  • If your plan is through your or your partner’s employer, contact your health plan administrator at work to find out more about the refusal.
  • Ask the doctor to write a letter explaining or justifying what has been done or has been requested. Keep a copy of this letter in case an appeal is needed later.
  • Ask your insurer if your employer’s health plan is self-insured, and on what date the plan started. This will help you figure out which rules apply and which appeals process to follow.
  • Talk to your state insurance department or the agency that regulates your insurance company to verify that the insurance company has acted properly and that the denial has not been made in error.

You can then re-submit the claim with a copy of the denial letter and your doctor’s explanation, along with any other written information that supports using the test or treatment that has been denied. Sometimes the test or service will only need to be “coded” differently. If questioning or challenging the denial in these ways doesn’t work, you may need to:

  • Put off payment until the matter is resolved. Keep the originals of all the letters you get.
  • Keep a record of dates, names, and conversations you have about the denial.
  • Formally request an internal appeal (or internal review) by the insurance company. Complete any forms the insurer requires, or write them a letter explaining that you’re appealing the insurer’s denial. Include your name, claim number, and health insurance ID number, along with any extra information such as a letter from your doctor. Your cancer care team may be able to help with this.
  • You have 6 months (180 days) from receiving your claim denial to file an internal appeal.
  • Find out if you live in one of the US states that have a special Consumer Assistance Program (CAP) that can help you file an appeal. (Check online at https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/
  • If you don’t live in a CAP state, get help from the consumer services division of your state insurance department or commission. Check the blue pages of your phone book or contact the National Association of Insurance Commissioners online at http://naic.org/state_web_map.htm, or call them at 1-866-470-6242.
  • Be persistent. Do not back down when trying to resolve the matter.
  • Find out about getting an external review

Don’t give up if you get another refusal.Even if your internal review is denied, it’s still worth another step – you may be entitled to an external review. Write one more letter asking if there’s anyone else in the company you should talk to. Be sure to say that you’ve exhausted your internal options. Ask about your independent external review options.

Most commercial health plans (those offered by insurance companies) take part in the federal external review process. This is the review of records from the case and the current medical literature. These are independent review boards with the power to overrule insurers. You can expect a fairly quick decision, usually within 60 days or less of filing, and much faster if you can show your case is an emergency. Visit www.cms.gov/CCIIO/Resources/Files/external_appeals.htmlor call toll-free at 1-877-549-8152 to learn more about both internal and external appeals. There you can also get a tracking form to help you keep up with each step of the appeals process.

An important step: Be sure to check whether Medicare covers the treatment you’re appealing. Medicare coverage often influences how other insurers act, even in non-Medicare cases.

Remember, too, that insurers often make simple bureaucratic mistakes. Read the fine print in your policy and don’t be afraid to contact health plans, doctors, and state regulators. Remember to keep detailed records so that you can refer back to them. Keep a log of all calls and save all correspondence. Keep a record of all authorizations and the names of people you’ve spoken to. Get a copy of your insurance policy, your employee policy booklet, and your Summary of Benefits notice. Ahealth plan is usually accountable for whatever it promises in a policy booklet, even if the fine print of the actual policy says something else.

Professional Help: If you still need help, contact the Patient Advocate Foundation a National non-profit organization that serves as an active liaison between patients and their insurers to help with the insurance appeals process. Call 1-888-879-4210 or visit them online at www.patientadvocate.org.

Para solicitar información en español, llame al 1-800-227-2345. Un especialista en información sobre el cáncer le asistirá en español.