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4 keys to appealing a rejected insurance claim

First Published Aug 13 2014 01:58PM      Last Updated Aug 13 2014 01:58 pm
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A physician can help detail how all treatment alternatives were exhausted before you started receiving the care an insurer deemed not medically necessary.

The insurer will want more than your doctor’s word, so be prepared to include any confidential medical records that support your case.

Consider including medical journal articles that support your argument or detail the effectiveness of your treatment. These can be especially helpful if your doctor is unable or unwilling to work with you on the appeal. Patients can use the National Institutes of Health website www.pubmed.gov to search journals around the world.

Make sure you directly address the insurer’s reason for denying coverage. Not doing so is the biggest mistake people make in filing appeals, according to Cheryl Fish-Parcham, private insurance program director for the health advocacy group Families USA.



Submit your appeals by certified mail so you can document when the insurer receives them and that you met any specified deadlines.

Be persistent. If the first appeal doesn’t work, the insurer should outline additional options that may include an appeal to a medical director who was not involved in the decision.

The insurer also may permit a peer-to-peer review, in which your doctor talks to a physician representing the insurer about your case.

3. GOING OUTSIDE THE INSURER

If you’re not happy with the insurer’s internal review, seek an examination from an independent reviewer. Be mindful of any deadlines for making such a request.

Some patients with employer-sponsored health plans also may be able to turn to their company for help. Companies with self-funded coverage — largely those with 200 or more workers — actually pay the medical bills and hire insurers to administer their plans.

The employer may learn through your appeal that its coverage is more limited than what company leaders intended, said Erin Moaratty, chief of mission delivery for the Patient Advocate Foundation, a nonprofit organization that helps patients with medical bills and coverage denials.

Even if the employer declines to overturn the insurer’s decision, it can be important for companies to be brought into the appeals conversation so that they can consider making coverage adjustments over time.

Check with your human resources department to see if your coverage is self-funded and if they can help you understand the appeals process or put you in touch with the right insurance representative.

4. SEEKING HELP

If you’re not comfortable shaping your argument, or you’re not physically up to it, you have a few options for outside help. Some states offer consumer assistance programs, and your insurer should provide you with contact information for the program in your state.

Help is also available from nonprofit agencies like Patient Advocate Foundation and The Jennifer Jaff Center, which can assist with appeals in cases involving chronic, life-threatening or debilitating illnesses.

 

 

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