How to fight a health insurance claim denial

A health insurance claim denial does not have to mean you are just out of luck when it comes to finding help to pay for treatment or care.

Discovery Health offers tips and resources about health insurance claims and denials on their Fit & Health website.

There is no hard number on just how many health insurance claims are denied each year. Formal complaints against health plans to the Department of Labor number around 91,000 and experts agree only a fraction of people experiencing problems file a complaint.

For those who experience a denial of coverage it is important to know the process does not end there.

Consumers do have recourse when a health insurance claim is denied, says Erin Moaratty, chief of external communications with the Patient Advocacy Foundation. PAF provides free advocacy assistance to people with long-term, debilatating or chronic illness.

“You should always look at the denial letter and determine what the reason for denial is,” Moaratty says.

Claims may be denied for any number of reasons from a simple coding error – basically a clerical mistake – to refusal to provide a certain procedure or treatment. Knowing the reason for the denial is the first step to preparing an argument against it.

Bonnie Schreck, director of clinical content for the Professional Patient Advocacy Institute, agrees.

“If a claim was denied, look at the itemized claim. Make sure all services being billed were actually completed,” Schreck says.

Compare the bill with the explanation of benefits from your insurer and keep that documentation as you move forward with the appeals process. Have the insurer explain why a claim was denied. Sometimes services and even prescriptions need prior authorization. Make sure to follow the rules of the policy. If you have followed the rules, move forward with the appeals process.

“Be persistent,” Schreck advises.

Health insurance plans are contracts, Moaratty said. Make sure you understand your policy and the recourse available when a claim is denied. Follow deadlines and document your efforts. Once a deadline is missed, it could derail the appeals process.

In the first level of appeals, which is directly to the insurer, prepare an argument as to why you disagree with the decision to deny the coverage. Avoid bringing your emotions into the appeal, Moaratty says. The need for medical services is often accompanied by a great deal of stress. Provide a brief synopsis of the medical situation leading into your argument, but don’t go overboard. Your personal situation is not going to impact the terms of the contract.

If the first level of appeal is unsuccessful, it may be possible to have the determination of coverage made by an impartial third party. For example, if a specific oncology treatment is denied, it may be possible to have an independent oncologist review the case and make a determination, Moaratty says. If a specialist review is available, be sure to request an expert in the field of care for the claim.

“It’s really important to get your provider involved too,” she says.  If the provider is able to provide evidence to support the need for the procedure or treatment it may help to resolve the claim. The foundation offers an appeals guide online to assist consumers.

Consumers may also be able to get assistance dealing with their insurer from an agency such as the Patient Advocacy Foundation, a local patient advocacy group or a private patient advocacy firm. Many local hospitals have patient advocates who have the advantage of being familiar with that facility.

If all else fails, depending on the type of policy, there may be legal recourse such as court injunctions.

“So even if it’s denied, there still could be argument for overturn,” Moaratty says.