How to Fight a Health Care Claim Denial

Sometimes it seems that health insurance companies go out of their way to reject medical care claims. That’s no accident — the fewer treatments, the less a health insurer must pay. But if you’re denied on an insurance claim, you do have some recourse — and that recourse should get stronger in September when new changes to health care law take effect.

Currently, health care plan participants have limited help in appealing insurance coverage decisions. Many states don’t provide an appeals process in the first place, and if your health insurance is funded by your employer, state laws don’t apply anyway.

That usually leaves you at the mercy of the big health care insurers, with predictable results. According to the U.S. Department of Labor, approximately 1 in 7 employer health insurance plan claims are rejected. Furthermore, only 4% of those rejections are appealed, according to the American Association of Retired People (AARP).

The landscape will change, for good or bad (but it seemingly can’t get much worse), on Sept. 23, when the federal government takes a bigger role in the health insurance appeals process. As part of the recently enacted health care reform bill, Uncle Sam will introduce an independent panel of health care specialists that will review appeals and make decisions based on the merits of a given claim. The board will be implemented in all 50 states, with each state’s insurance commissioner appointing individual board members.

According to the state of Kansas’s insurance commissioner’s office, about half of all health insurance denials could be reversed under the new advisory commission guidelines.

Until then, there are some steps you can take to turn the tables on your denied health care claim:

Know what your plan covers. Read through the terms of your health care plan and you should be able to figure out what will pass muster and what won’t. You’ll save a lot of grief by knowing what your plan covers before you start filing a denial claim. If you’re not sure, call your health insurance provider and ask them – before you undergo any medical treatments or procedures.

Check for authorization. Many health insurance carriers will allow some wiggle room on medical care they may not normally cover. But to get that clearance, you’ll have to ask your provider in advance for written authorization allowing the treatment. Don’t ask after the fact — they may not approve the treatment and you’ll be stuck with the bill.

Save all medical records, and all copies of your health insurer’s denial of your coverage. Mistakes happen all the time, and it’s quite possible that a customer service representative or billing staffer popped in a bad code for your claim. Make sure to check with your insurance provider to ensure that no mistakes were made in the denial process.

Keep an eye on the clock. If your insurance provider denies you a second time, you’ll have 120-180 days (depending on what state you reside in) to file an appeal with your state’s insurance commissioner. Send all available records and letters from your provider. Expect a decision in about 45 days.

Things may get a bit easier Sept. 23, when the independent review panel option fully kicks in. But the best way to fight a claim will remain the same — keep good records, look for errors, and keep fighting the good fight.

—For the best rates on loans, bank accounts and credit cards, enter your ZIP code at BankingMyWay.com.

Show Comments

Back to Top