Even if you’ve done everything you can, your health insurance company may nonetheless deny your claim for a necessary therapy or medicine. In reality, according to the experts, appealing a rejection and persuading the insurer to rethink is possible. There are situations when a patient’s insurance company gets incorrect information, says Teri Dreher, president of North Shore Patient Advocates in the Chicago region. Then there are occasions when it’s not a wise decision. Because insurance companies are difficult to work with, people tend to just pay out of their own pockets rather than file an appeal, according to Dreher.
Tips for fighting against an insurance claim
The Bexfield case serves as a powerful reminder that even the most difficult cases may be won with persistence. These suggestions from insurance claim specialists may help you deal with your own denial:
Patients who have had an insurance claim denied should first study their plan paperwork to see if there are any discrepancies, according to Bruce D. Roffé, PsyD, MsS, HIA of H.H.C. Group, a medical claims expense reduction organisation based in Gaithersburg. “That contract establishes the health plan’s commitment to pay for specified health care services in terms of their duties.” Look at the Benefits Summary: According to Adria Gross, a New York State-licensed insurance broker and consultant who runs MedWise Insurance Advocacy and is the author of Solved!, you should also check the Explanation of Benefits, or EOB, which explains why you have been denied and provides the name and address of where to appeal your claim. Taking Care of Your Health Insurance Issues.
Send an Appeals Letter: A patient’s claim can be appealed to the insurance company, which will then have a nurse or physician analyse it internally. Roffé explains, “This evaluation is undertaken to clinically assess if the care should be allowed.
Take a look at every option: It’s possible to apply to the state or federal government for an external review by an approved independent review organisation (IRO) if your appeal is rejected, he explains. “The ultimate decision is made by the IRO and returned to the state or federal government, the patient, and the payor. Depending on the applicable state or federal legislation, the patient may decide to pursue additional review through the legal system.
Pay attention: That’s why Roffé emphasises the need of letting patients know that all relevant medical records must be submitted to the IRO for an impartial examination. In the end, it’s up to the patient and their doctor to make sure all of their paperwork is in order. It is true that a review is only as good as the data it receives.
Your service provider should be involved in the appeals process: When it comes to facts, Carriers aren’t always correct.” As Gross points out, getting your supplier to supply extra information or to rephrase their submission might make all the difference.
Here are a few more ideas to help you succeed: According to Gross, it’s important to keep track of every phone conversation you have with your insurance company discussing a potential claim. To ensure that you don’t forget important details like the time and persons you spoke with, make sure you take notes. You should preserve a copy of every letter you send or receive, together with any supporting documentation, such as the policy number and details of your claim. There is power in the minutiae of a case file.” Even if the insurance is testing your patience, make an attempt to stay nice. “No matter what, do not be nasty or aggressive. She warns that it might jeopardise your case.
Get help from others: A patient advocate may be able to aid you in your efforts to battle your insurance company isn’t making any impact. In the event that a patient needs aid negotiating or advocating, the Patient Advocate Foundation is there to help.
Try something new. Think beyond the box when everything else fails.” For Bexfield to be successful, he had to “pull numerous rabbits out of the hat”. My garage is covered in insurance denials, so I thought that could help. Perhaps not directly, but it served as a constant source of inspiration.”