NASE News

Health Insurance Help

Sooner or later, everyone who has health insurance encounters questions about their coverage or has a claim denied. Fortunately, most questions are easily answered by calling your insurer’s member services number. Fixing a claim denial often amounts to nothing more than supplying data that was missing or incorrect in the first place.

But what if you, a family member, or one of your employees runs into a problem that is not so easily solved? Where can you go for help?

First, try the agent that sold you the policy. If you did your homework before you purchased the policy, you selected someone that you were confident would offer you personalized attention and act as a liaison between you and your insurer if you or your employees should ever have any questions or problems. Hold him or her to that promise.

If the agent can’t help, contact your insurance company. Many insurance companies have extensive customer service departments that can answer questions regarding your coverage and assist you with any claim difficulties. If your agent or your insurance company were unable to solve the problem, contact your state Department of Insurance (DOI). You can find contact information for your DOI at www.naic.org. Many state DOIs have consumer health insurance advocates or managed care ombudsmen that can help you untangle a problem. State DOIs often sponsor Web sites that will point you in the right direction. Another good alternative is your state Department of Health. Check health department Web sites as well for consumer health insurance information.

Know Your Plan’s Rules

Most members do not read the handbooks their health plans give them, according to a study by the U.S. General Accounting Office, so many denials are simply a result of the members’ ignorance of their plans' requirements. Make sure the treatment you are planning on receiving is covered under your insurance before treatment is received.

A Word About Web Sites Featuring Healthcare Content

There are thousands of online resources for health and insurance information, but it is often difficult to distinguish which Web sites feature information you can trust and which are mainly advertising portals. The Internet Healthcare Coalition, located at www.ihealthcoalition.org, is a non-partisan, nonprofit corporation that offers Tips for Health Surfing Online. Adhering to these guidelines will help you search safely for consumer health care information. According to the Coalition, a good rule of thumb is to find a Web site that has a person, institution, or organization in which you already have confidence. If possible, you should seek information from several sources and not rely on a single source of information.

 

Document Everything

Keep all your records, not just the denial-of-care notice. This includes any and all correspondence from the insurer and a detailed phone log that documents the name of the people you have spoken to, their titles, and the date you spoke to them. Jot down the general gist of your conversation. This will prove invaluable if you have to reconstruct the steps you have taken thus far to resolve your problem for an independent panel.

What to Do When Your Claim is Denied

 

Even if you’ve read and followed all your health plan’s rules, you may still one day wind up with a claim denial. Although your immediate reaction may to be to get angry, don’t take the notification of denial of payment personally. More likely than not, a computer software program automatically generated the decision. Don’t forget that most billing and pre-certification communication between your doctor and your insurer is in codes. One misplaced number can mean the difference between an approval or denial.

If calls to your insurer’s member services don’t help, ask your physician’s office for help in pleading your case. Health insurers grant or deny treatment based on whether a treatment is “medically necessary” for your well-being and whether the treatment is appropriate for your health condition. Ask your doctor to contact your insurer on your behalf.

Information Your Insurer Should Provide With Your Denial

  • A statement of specific medical reasons for the denial.
  • A statement identifying the treatment exclusion.
  • The name, state of licensing, medical license number, and title of the person making the denial decision.
  • Instructions for filing an internal appeal, including whether your appeal has to be in writing, time limits, and the name and phone number of a contact person.

If you do not receive this information from the insurer, ask for it in writing.


When to File An Appeal

If initial phone calls by you and/or your physician to straighten out the denial are unsuccessful, it’s time to file a written appeal. Make sure you review your health plan’s appeal process so you don’t miss any important deadlines. Some plans require you to file an appeal within 60 days of the denial. In the event that you or your employee needs a treatment decision within 72 hours, find out your plan’s requirements for an expedited appeal.

There are usually two methods of appeal: internal and external. The internal appeal is to the insurer; an external appeal is to your state department of insurance or other governing body. During the internal appeal, you request more information and ask the insurer to reconsider its decision. External appeals are filed when internal appeals have been exhausted and your insurer won't reconsider your case.

Many states have implemented laws governing external appeals that in certain cases give you the right to a review by an independent review board of qualified experts. If the appeal is determined in your favor, your insurance company cannot deny your claim.

When appealing your denial, it is essential that you find the correct person to whom you should send your appeal letter. If you're not sure, call your plan’s member services and ask for the name and address of the appropriate person. Also, send all letters by certified mail so you have a record of having sent the letter and a receipt that it was received.

Sample appeal letters can be found at the Patient Advocate Foundation’s Web site, located at www.patientadvocate.org. The Patient Advocate Foundation was founded on behalf of cancer patients seeking insurance payment for evolving cancer therapies.

Finally, if you absolutely need the treatment or medication, get it anyway and file an appeal later when there is less stress involved. Delaying treatment is never a good health care strategy.