A serious illness is hard on the body and the mind. If your health plan refuses to pay some of the bills, you may feel too weary to fight. But you have a right to appeal those decisions, and the odds of success are better than you may think.
Health plans deny claims for all kinds of reasons. Your insurer may argue that a surgical procedure is experimental or your medication isn’t “medically necessary.” Your plan may decline to pay the full amount because an out-of-network doctor performed the service. Sometimes, claims are denied because they were coded improperly.
The problems are compounded for people with chronic illness, who often file dozens of claims, says Jennifer Jaff, author of “Know Your Rights: A Handbook for Patients with Chronic Illness.” “The system is built for people who get sick, get treated and get better,” she says.
Jaff – who has battled Crohn’s disease, a chronic inflammation in the small intestine, most of her adult life – says individuals with chronic illnesses often have to fight for coverage. “We are absolutely by far the most expensive bunch of people, so insurance companies will look for reasons to deny coverage.”
But just because a claim is denied doesn’t mean you should pay it. All states require health insurance plans to have internal review procedures, and about 70 percent of appeals are successful, Jaff says.
How to improve your chances:
•Make sure you understand the reason for the denial. The letter you receive from your insurer should explain the reason your claim was denied and may offer to provide documents supporting that decision. “Collect as much information as you possibly can,” Jaff says. That will help you determine how to frame your appeal.
•Ask your doctor to write a letter on your behalf. The letter should include a brief medical history and diagnosis and an explanation why the medication or treatment is necessary. If you’ve tried other medications or treatments, explain why they were ineffective, Jaff says.
•Write a cover letter explaining the basis of your appeal. For example, your letter may state that the insurer didn’t consider all the evidence in your case or misread information provided by your doctor. Include evidence to support your contention, such as blood tests, MRIs or CAT scans, Jaff says.
•Keep detailed records. Dan Robinson’s son, Zane, was born four years ago with a rare disorder that required open-heart surgery when he was 2 months old. Right after that surgery, the first of several operations, “We started getting tons of bills,” Robinson says. “I knew just looking at the pile of them that it was way more money than I should have to pay.” At one point, Robinson was filing up to 10 appeals a month.
Robinson created a computer program to track his son’s bills. It proved invaluable in filing appeals, he says. In many cases, claims were denied on the grounds that a particular doctor wasn’t included in his plan’s network. Robinson’s record-keeping system helped him prove that the doctor in question was covered by the plan.
Robinson, who was working for software maker Intuit at the time, used his experience to develop Quicken Medical Expense Manager, a product designed to help families organize their medical records.
Whether you use a computer program or a file folder, keep detailed records of correspondence with your insurer, medical records and bills. Take notes of phone conversations. Send letters through certified mail and request a return receipt. That way you can confirm they were received.
•Pay close attention to deadlines. If your insurer says you have 60 days to appeal, make sure you meet that deadline. Otherwise, you could lose your right to appeal. If you don’t have all the information you need, state in your letter that you’re expecting more information and will submit it as soon as possible. Likewise, if you’re too ill to send a detailed letter, send a short letter explaining the basis for your appeal, and tell the insurer you’ll provide more information when you can.
•Ask for an independent review. Many insurers contract with doctors or other outside experts to review claims disputes. Try to provide new information that wasn’t included in your first appeal, Jaff says.
The next step
If your insurance company refuses to change its initial decision, you still have options. However, your rights differ de pending on the type of plan you have.
Where you can go for help:
•State external review boards. Some 43 states and the District of Columbia have established independent boards to consider denials of health insurance claims. Most states won’t consider an appeal until you’ve exhausted your insurance company’s internal process.
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