July 11, 2016
By: Lisa D. Ellis
Featured on qualityhealth.com
If your health insurance company denies a claim for a needed treatment or medication, you may feel helpless and wonder if there's anything you can do to fight the decision. In fact, the experts say that there are strategic ways to appeal a denial and get the insurer to reconsider.
"Sometimes, denials are because the carrier has poor information," says Teri Dreher, president of North Shore Patient Advocates, a patient advocacy agency based in the Chicago area. "And sometimes, it's a mistake. But because insurance carriers aren't easy to deal with, people often give up and pay out-of-pocket rather than appeal," Dreher says, adding, "However, appeals can be won."
Persistence Pays Off
David Bexfield, who lives in Albuquerque, NM and was diagnosed with Multiple Sclerosis (MS) a decade ago at the age of 37, is living proof of the concept that anyone can win if they try hard enough.
"I may have one the most successful examples of overturning an insurance denial in a case that was considered virtually impossible. It was featured in 2014 in the New York Times, and resulted in a reimbursement of over a half million dollars," says Bexfield, who runs a blog about Multiple Sclerosis (MS) at www.ActiveMSers.org.
Bexfield received a stem cell transplant that stopped the progression of his MS and eliminated the need for medication, yet his attempts to get his insurance company to pay the $200,000 bill for the treatment failed because at the time of service, this procedure was not a covered benefit (although it became one shortly after his treatment was finished). It took Bexfield four years, multiple denials, and endless frustration, but he was finally able to get the insurer to reimburse the treatment expenses—along with interest on the money he had laid out for these medical bills.
Tips to Fight Back
Bexfield's case is a strong reminder that even the toughest cases can be won if you stick with it. To help you deal with your own insurance claim rejection, you can try some of the following tips from the experts:
- Review your plan: "If a patient has submitted a claim for a treatment/service/procedure and it's denied by an insurance company, the first thing the patient should do is to review their plan document," says Bruce D. Roffé, P.D., M.S., H.I.A., President and CEO of H.H.C. Group, medical claims cost-reduction company located in Gaithersburg, MD. "That document defines the obligation of the health plan in terms of their responsibilities to pay for specific health care services."
- Check the Explanation of Benefits: You should also check the Explanation of Benefits, or EOB, which explains why you have been denied and provides the name and address of where to appeal your claim, according to Adria Gross, a New York State-licensed insurance broker and consultant who runs MedWise Insurance Advocacy and is the author of Solved! Curing Your Medical Insurance Problems.
- Submit an Appeal: A patient can appeal to the insurance company, where the claim will be reviewed internally, usually by a nurse or physician. "This review is conducted to clinically determine whether the care should be approved," says Roffé.
- Explore every avenue: "If [your appeal] is denied, the patient may apply to the state or federal government for an external review by a nationally, accredited independent review organization (IRO)," he points out. "Once the IRO makes a determination and returns it to the state or federal government, the patient, and the payor, that is the final decision. The patient may choose to pursue further review through the judicial system, depending on the applicable state or federal statutes.
- Be diligent: "It is important that the patient understands that all relevant medical records must be submitted to the IRO so they get a fair review," Roffé stresses. "The onus is on the patient and their physician to make sure that their documentation is complete. In many instances, the review itself is only as good as the information that is submitted."
- Enlist your provider in the appeal process: "Carriers don't always have the right facts. Asking your provider to submit more detail or reword their submission can make all the difference," Gross points out.
- Other tips to help increase your odds for success: "Keep a detailed log every time you call your carrier regarding a claim," Gross says. "Record the date, the names of the people you speak with, and exactly what was said. Keep copies of all written correspondence and keep the facts of your case handy, including your policy number and claim info. A detailed record can make a difference." Also make a concerted effort to remain polite, even when the insurer is trying your patience. "No matter what, don't be confrontational or rude. It can hurt your case," she says.
- Use outside resources: When your efforts to fight your insurance company don't seem to be making a difference, you may want to hire a professional patient advocate for help. The Patient Advocate Foundation offers a wealth of advice and helpful resources and negotiates or advocates on a patient's behalf as needed.
- Get creative. "When all else fails, think outside the box. I pulled many rabbits out of the hat to succeed," Bexfield says. "Did wallpapering my garage with insurance denials help? Maybe not directly, but it provided daily motivation."
Bexfield, David. Blogger., email interview, May 2, 2016.
Dreher, Teri. North Shore Patient Advocates, email interview, May 2, 2016.
Gross, Adria. MedWise Insurance Advocacy, email interview, May 2, 2016. http://medicalinsuranceadvocacy.com
Roffé, Bruce D., P.D., M.S., H.I.A. H.H.C. Group, email interview, May 2, 2016.
Bruce. D. Roffé, P.D., M.S., H.I.A. H.H.C. Group approved this article.