Appealing Health Insurance Claims


How to Successfully Appeal a Health Insurance Claim Denial

Cancer patients often are faced with steep bills when their health insurance carrier denies a claim or partially pays the claim. Some health insurance companies make the same mistakes over and over again (e.g., misclassifying a diagnostic test so as to generate a higher co-pay) or deliberately force patients to appeal many claims. Perhaps they hope that the patient will give up and pay the bill instead of jumping through the hoops erected by the insurance company.

A few helpful tips include:

  • Do not accept 'no' for an answer. If the person you're talking to keeps on saying 'no', ask them if they have the authority to make exceptions, and if they say no, ask to speak to someone who can.
  • Ask for an expedited appeal.
  • Get your oncologist on board -- have him write a letter of medical necessity.
  • Often hospitals have staff who help families deal with insurance companies. Ask them for help.
  • Put your request in writing to the insurance company, in addition to speaking with them on the phone. Certain rights are only preserved when you make the request in writing. A written request is also harder to ignore, since a piece of paper must be dealt with.

If you are still unsuccessful, try escalating the complaint:

  • Write a letter to the state insurance commissioner.
  • Call or write your Senator and Representative, asking them for help. They have aides whose sole job is to write letters (signed by the Congressman, of course) to help their constituents.

It pays to have a copy of your full health insurance plan document (not the short 2-page summary, but the 100-pager) and to be persistent in appealing claims.

During one of my hospitalizations, I was admitted to the oncology ward, which has only private rooms. My health insurance policy doesn't cover private rooms, so they wanted to hold me responsible for the difference in cost between a private and a semi-private room. In this case it amounted to a total of $10,196 in addition to the $100 deductible.

My oncologist faxed a letter to the insurance company, stating the medical necessily of private room confinement (i.e., risk of infection due to neutropenia). He also mentioned that the oncology ward has only private rooms for this reason.

The insurance company was going to deny the appeal, on the grounds that medical necessity was insufficient with regard to hospital room and board, but I found a clause in the health insurance plan document that says that although the plan normally pays only the average semi-private room rate, it will pay 90% of the average private room rate if the hospital only has private rooms.

I appealed on the basis of that clause, and was successful. They reduced the "patient responsibility" portion to $982.80 plus the $100.00 deductible.

As a follow-up, I submitted a "special circumstances appeal" to the insurance company for the remaining $982.80 on the grounds of medical necessity, and they allowed it. So all I had to pay from the original $10,196 bill is the $100 deductible.

Even after successfully appealing every claim that I could appeal, I still had thousands of dollars in health-related expenses. But it could have been much worse.

Copyright © 2005-2018 by Mark Kantrowitz. All rights reserved.

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