Don’t accept a medical insurance decision you think is wrong. Fight back!
When Your Insurance Won’t Pay
For those of us lucky enough to have medical insurance, the rejection of a claim can come as a rude shock. After all, we have been paying a monthly premium with the expectation that the cost of care will be covered when we need it. The insurer’s decision can seem arbitrary, nitpicking or just plain wrong. Still, as much as we may need help to pay for a particular treatment, the prospect of fighting a bureaucracy can seem daunting and futile. Trust us: It doesn’t have to be that way. When your insurance company tells you “no,” following a few simple steps often can get the decision reversed in your favor. Here are the critical points:
- Don’t get angry—but do get involved. Insurance companies want to keep costs down, and that means denying payment for care and medications that they feel are not positively necessary. Don’t take this personally. A denial-of-care notice—usually a letter or other official statement that denies payment for certain care but not “care” per se—is often just a simple business decision made by a computer or after a cursory review by insurance-company employees.
- Hold on to your written records—not just the denial-of-care notice but all correspondence from the insurance company, in the event that your case escalates over time and eventually is heard by a panel of reviewers.
- Talk to your doctor to determine if the denied coverage is for a treatment or drug that he or she thinks you absolutely need, rather than something that may be helpful. Patients sometimes misunderstand their doctor’s intentions.
- Realize that most plans base coverage on a concept called “medically necessary.” Simply put, this means that, without the care in question, your condition could get worse. It does not mean that you are entitled to the newest high-tech treatments, especially if they are not yet fully tested.
- Do some research. Many medical organizations have set up “practice guidelines”—suggested standards for basic care—which you will find on their Web sites. For instance, if coverage is denied for a drug that’s widely prescribed after a heart attack, you could use this fact to further your case. (There are various Web sites. See americanheart.org, for example, and type “practice guidelines” in the search box.)
- Call your insurance company and say, “I am appealing my denied care.” Then put it in writing. When you call in a complaint, it likely goes to a customer-service department, where there is no legal time constraint to respond. By initiating an appeal, the insurance company—generally by law—has to begin a timely review of your case, which ultimately may be decided by a neutral outside panel. Follow up the call with a traceable letter in which you again use the word appeal. (Send it by certified or registered mail, overnight delivery or fax, making sure to keep the respective receipts for your records.) Then, have faith. Studies show that about 50% of the cases that go to neutral outside panels are decided in favor of the patient.
- Notify your department of human resources. Send a copy of your letter to the head of personnel or human resources (HR) at work. Since this department actually purchases medical and other insurance on your behalf, the insurance company sees it, not you, as the customer. When the HR department puts pressure on the insurance company, things happen.
- Finally, if you think a treatment or medication is urgent or required, get it. Launch an appeal later, when you have less to lose. Trying to save a few dollars by delaying care is never worth the risk to your health. The ultimate solution to many of these problems really begins at home. Prevention and wellness are preferable to any kind of treatment. But when treatment is required, don’t be afraid to go to bat against your insurance company and turn its “no” into a healthy “yes.”
Let Your Doctor Help
Enlisting a doctor’s help in the appeals process can make a big difference in your case. Doctors are used to dealing with insurance companies, and they know the lingo. That’s why it’s a good idea to cultivate positive relationships with your health-care providers.
Ask your physician to:
- Write a letter of “medical necessity” about the treatment or medication in question for you (or the doctor) to submit to the insurance company.
- Speak with one of the nurse reviewers or medical directors who is reviewing your case for the insurance company.