Handling an Insurance Dispute

HANDLING AN INSURANCE DISPUTE

If you notice a mistake on a health insurance claim or are denied coverage for a procedure, there are steps you can take to correct them. Some insurance disputes can be fixed fairly easily, such as a doctor entering a wrong billing code. Others may be more complex, such as figuring out whether or not a specific procedure was included in your plan coverage. When you have an issue, first review your health plan’s benefits and call your insurance company if you discover a discrepancy.

Here are some websites that can provide step by step advice for how to go about sorting-out your insurance issue:

About.com’s “Fighting a Health Insurance Claim Denial” can provide you with some insight into what the next steps should be.
eHow Money has some quick tips on “How To Resolve a Resolve a Claim Dispute With Your Health Insurance Provider.”
The Wall Street Journal article “How to Appeal a Health Insurance Denial” provides advice and resources to help with the process.
Consumers Union and The Henry J. Kaiser Family Foundation created in 2005 a “Consumer Guide to Handling Disputes with Your Employer or Private Health Plan.”
NOLO Law for All, a legal website, provides a brief overview of health plan disputes and information that may guide you.

Organizations That Can Help

If you have tried to handle the issue on your own with no success, it may be time to turn to professionals who can help you. Be cautious of organizations that want to charge you money to help you resolve an insurance issue and try options that offer free services.

The Patient Advocate Foundation is a nonprofit providing mediation and arbitration services to patients, providers, family members, and caregivers of those dealing with significant medical issues.

If You Do Have to File an Appeal, Some Advice

Here is some advice from the group Advocacy for Patients with Chronic Illness, Inc. on steps to take for filing an appeal when you have a disagreement with your health plan about what is covered by insurance versus what you have to pay for out of pocket.

Don’t:

Your insurance company will tell you that if you want to appeal, you can just call them. Never do this without first doing some research. If you don’t provide the insurer with new information, there’s no reason to think that, if they review the same information they already had, they will reach a different result. You have to give them something that will change their minds.
Resist the urge to sit down and write a letter saying your doctor says you need the test or treatment and you pay your premiums, so they should cover it. Your insurer already knows your doctor ordered the test or treatment. When an insurance company denies coverage, it’s usually because they believe it’s not medically necessary or it is experimental / investigational, so these are the concerns you must address.

Do:

To appeal a coverage denial successfully, the first thing to do is to collect your medical records. You need objective evidence, test results, labs, and doctors’ office notes to establish your diagnosis and medical necessity.
Often, a medical necessity denial is really a denial of an expensive test or treatment when the insurance company thinks there is a less expensive, medically equivalent alternative. A medical record that shows you’ve tried all the alternatives is the best way to address this, but sometimes the problem is that their suggested alternative really isn’t medically equivalent. In that case, the best thing to do is get a letter from your doctor explaining why it’s not medically equivalent for you.
Gather medical journal articles that support the safety and effectiveness of the treatment in question. You can search for abstracts or summaries on www.pubmed.gov, which is the library of the National Institutes of Health.
Once you have the medical records and the medical journal articles, you need to write a cover letter detailing, with dates, how the medical records establish your diagnosis and all of the treatments you’ve already tried and how the medical journal articles establish the safety and effectiveness of the treatment in question. The more detailed your letter, the better.

According to Advocacy for Patients with Chronic Illness, which provides free information, advice and advocacy services to people with chronic illnesses, 70 percent of insurance appeals are successful.

Original post by the Center for Advancing Health. Updated by the GW Cancer Institute January 2016.