Questioning Your Insurer's Decisions

(Click here for printable version)

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, and even if you lose on your first appeal, you have a good chance of winning on a second appeal. Patients who lose on a second appeal still have options, and can then contact independent state review boards or consult a lawyer.

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 a few tips:

  • Don’t call, instead, write a letter acknowledging receipt of a denial.
  • State the grounds as you understand them.
  • Attach copies of medical records.
  • Don’t sound angry.
  • Make a reasonable argument, backed up by evidence, showing why your denied treatment is “medically necessary.”

If your appeal is rejected, appeal again. The first refusal may offer several reasons for rejection of coverage. The second letter will likely focus on the key reason for refusal. Get a letter from your doctor, and even a second opinion from another doctor, showing why the procedure was a medical necessity. Look for articles online or in professional medical journals that show the procedure is an accepted medical treatment.

Don’t give up if you get a second refusal. Even if the letter states: “This is your final appeal,” it’s worth another step. 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. This will pave the way for outside options such as a state review board or legal action.

State review boards are made up of medical specialists in the disputed area. They review records from the case and the current medical literature. Most states have 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. The appeal is either free or costs a small filing fee. You don’t need to hire a lawyer, but many people find they need some expert help to navigate the system. And getting the necessary back-up material together may take you weeks or months. Most states give full information on what and how to appeal on their Web sites. (Search for your state’s “medical review board.”)

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 policy and your employee policy booklet. A health 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.