Tips for appealing denials from insurance companies

[imisspopcorn]

I found this info in a free magazine I receive from the manufactures of Cimizia. It is called Crohn's Advocate. Anyway, I thought this info might be helpful for people who have to fight their insurer!


Taken from the Crohn's Advocate winter 2010

According to the Advocacy for Patients with Chronic Illness and the Office of the healthcare Advocate, 96% of insurance denials are NEVER appealed. But those that are appealed have a success rate of 80%!


Here are some tips for appealing an insurance denial


Determine why your claim was denied

Don't try to guess why your insurer denied your claim-they can range from questions of medical necessity to stipulations against experimental or off label use of drugs. Your appeal will be based on the reason for denial, so get the information and then develop a plan of attack.

Get your paperwork in order.
Once you've figured out the reason for denial, gather necessary documents-medical records, journal articles, and letters from your doctor explaining medical necessity to help make your case.

Write a letter of appeal

While it might be tempting, calling your insurer to plead for medicine won't get you far. Write a compelling letter about your situation, using documents you've gathered as attachments that provide evidence to make your case. The better and clearer your explanation, the more likely you are to win.



For more information on appealing an insurance decision, visit the Advocacy for Patients with Chronic Illness Web site at www.advocacyforpatients.org

 

[D Bergy]

If you are pretty sure you are being denied without a just cause, and your appeals have not helped, do not hesitate to tell your insurer your only recourse is to bring the matter before the state insurance commissioner.

Insurance companies do not like attention from the state concerning their business. If the threat does not work, do contact the insurance commissioner of your state, probably in writing, and ask them for help.

A denial does not mean they will not pay. It can be just part of the companies efforts to pay as little as possible, or an honest mistake. They take advantage of the fact that most people do not question a denial.

Dan

 

[saidinstouch]

To what both Dan and IMP said, that is VERY good advice. I have had issues with both Blue Cross and PacifiCare in the past and in both cases my mom wrote letters to the insurance commissioners office. We didn't know it at the time, but one of our communications led us to be a part of an administrative action against pacifiCare in CA as one of two patient witnesses. You may not realize it, but apparently these people do in fact care and do actively investigate your claims.

Sometimes all it takes is mentioning you are contacting the commissioners office and a day later or less the claim is "magically" approved. I once even had a member of the commissioners office call Blue Cross for me because not only were they not approving my medication, they weren't denying it either. This way I couldn't even appeal the decision or request an independent review. In California once you are denied you are allowed to request an appeal and then 30 days later when it is denied, you can have an independent medical board perform a legally binding review (granted 30 days is a long time to wait). They gave HER the run around and told her that they were essentially not going to approve my medication anytime in the near future, so she had me start this process. I called them and requested an appeal (which they said I couldn't do because it wasn't denied...so I told them their lack of approval in over two weeks was a clear denial), and then the next day or so I think I suddenly had my approval. I'm fairly certain I caused enough commotion that the higher ups at Blue Cross for my plan got scared and approved it on the spot once they realized I knew my rights.

The message of this story is...goto the companies acting like you know your rights. If you don't know them, contact your insurance commissioner and browse their website to learn them. When you know your rights better than the drone on the phone at a call center, you will get the service you need a lot faster. Also, don't hesitate to ask the first person on the phone to give you to a supervisor/manager immediately and have a brief 20-30 second explanation of why. They will pass you off quickly and then you get to speak to someone with a bit of power to fix the problem, not a grunt who is basically told to deny everything and push blame elsewhere.