Don’t take no for an answer when it comes to your medical insurance coverage. You pay your premium every month and have an expectation that your insurer will cover the cost for care when it is needed. Having your claim rejected can come as a shock. The insurance company’s decision can seem vague or wrong — especially after you have tried other options such as treatment or intensive outpatient therapy and you still need more help. The idea of trying to fight the bureaucracy of the insurance claim process is overwhelming, but it is worth it — especially when the decision is reversed in your favor. Here are some guidelines for help:
1. Enlist Your Doctor’s 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. Have them write a letter explaining that other avenues have not worked and it is critical to intervene.
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 are reviewing your case for the insurance company.
2. Don’t Get Upset
Insurance companies want to keep costs low, and that means denying payment for care and medications that they feel are not absolutely necessary. A Denial of Care Notice—usually a letter or other official statement that denies payment for certain care—is often just a simple business decision made by a computer or after a cursory review by insurance-company employees. Stay strong. You have to do your due diligence and go the distance.
3. Ask for Clarification
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.
4. Understand the Approval Process
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. Having your doctor write a letter will help with this.
5. Appeal Your Case
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. 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 (this is good). Follow up the call with a traceable letter (email) where 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.)
Studies show that about 50 percent of cases that go to neutral outside panels are decided in favor of the patient.
Keep track of your records and all correspondence with the insurance company, in case your file escalates over time and eventually is heard by a panel of reviewers.
6. Get Support
Send a copy of your letter to the head of personnel or human resources (HR) at your workplace. 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.
Do some research; many medical organizations have set up “practice guidelines”—suggested standards for basic care—that you will find on their websites. 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 websites. See Regency Blue Shield, for example, and type “practice guidelines” in the search box.)
7. Don’t Wait
Most importantly, if you think a treatment or medication is urgent or required, get it. Get help. 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.”
