We’ve heard plenty of horror stories about people’s coverage being denied for situations where they’re darn sure that they were covered, and now, an insurance industry insider has come forward with some tips on how best to make an appeal.
These steps assume that you have gotten treatment and are certain that your policy covered your doctor, service, and diagnosis.
“1. Call the insurance company to get a clear explanation of the denial.
2. If they do not believe it is an error, ask if there is any way that a 1 time “pay and educate” exception can be made to cover it. For many small dollar situations, large companies will make a one time exception without having to proceed further.
3. For denied claims, ask the insurance company the exact reason for denial.
3a. If it is a policy exclusion, they should be able to reference what the exact exclusion is in your policy. If it is truly excluded, the company may have no right to actually pay the claim. Polices represent contracts and paying an exclusion for you can potentially get the insurance company in trouble with the department of insurance.
3b. If the denial is due to the provider not participating with your policy/insurance company, ask if there has been a change in the provider recently. For situations where that has not happened, be sure to include why you believed the doctor to be in your network in your appeal.
3c. If a denial is due to a medical guideline, check with you doctor. You should be able to get guidelines on the exact medical criteria from the insurance carrier, sometimes just from the website. By consulting your doctor’s office, you may be able to provide information to show that you do meet whatever criteria led to the denial.
4. Finally, if the above does not work, be sure to follow the appeal process that is outlined in your policy document. In the appeal, make sure to explain exactly what happened and why you felt the process you followed was correct. In the appeal letter, try to explain your case to show that you understand the process/coverage now and that you would have followed the guidelines if you had known before the service.
5. If your appeal is turned down, follow the steps to continue to the next level appeals process, but make sure to respond to the denial letter with more information rather than just resending the same letter again.
If you follow these guidelines, this should provide what you need for getting a fair shake with the appeals team.”
Thanks, Deep Ears, Nose, and Throat! Have any of you readers been in a situation where the insurance company denied coverage when you thought it was covered? How did you deal with it?
(Photo: Getty)
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@SkokieGuy: You’re welcome. I’ve got to get back to work too.
@HIV 2 Elway: “Minimizing risk has to be a part of their business plan.”
That’s quite irrelevant if the risk in question is covered by the terms of the insurance product in question. By your standard, Toyota could increase my monthly payment on my new car if their profits went down last quarter.
@HIV 2 Elway / You are an ass!
@BigElectricCat: We’re not comparing the same things. You’re talking about not honoring coverage already extended to a customer. That’s bogus. I’m talking about not insuring a high risk customer in the first place. If a policy is granted, it needs to be honored. However, it’s unrealistic to think that insurers should have to insure anyone who applies.
Just as an aside about the cost of health insurance, not everyone can get a good job that provides good benefits, regardless of their education level, unless they are willing to relocate (and even then it can be a challenge).
The company I work for toyed with providing health care for its employees for less than a year. If we wanted insurance for just ourselves, it cost us $25 per month, or about $300 per year. If we had the audacity to request coverage for our spouses, this suddenly increased an additional $200 per month, for a total of $2,700 per year (incidentally, this was nearly 15% of our gross income). One of our employees had three children. He tried to get coverage for them and ended up losing over half of his NET paycheck every month.
I developed epididymitis while we had insurance, and was fortunately covered for ALMOST everything (I had to pay $100 for the emergency room visit, and another $100 for an ultrasound – I never got a good explanation for why I was denied coverage on the ultrasound, since it was an important part of actually diagnosing me).
That was a random tangent, but something to consider is this: what is the point of HAVING insurance if they are simply going to deny you coverage (either outright or when you develop a severe enough condition) when you become a liability? I thought the whole point of health insurance was making sure that you could afford these inflated health-care prices that insurance companies helped create? Suddenly, I see that the REAL point of health insurance is to pad the pockets of large conglomerates, while still forcing you to pay the same ridiculous health-care prices. I guess I’ve learned my something new for the day.
And you wonder why conservatives and liberals alike shudder at the thought of Hillary’s mandatory health insurance plan. I don’t want to be forced to pay someone money to tell me that I can’t be covered!.
Specifically @ HIV 2 Elway:
Stop and think for a moment, though: Who needs insurance more? The healthy person who might end up in a bad accident, or the person genetically pre-disposed to cancer who will very likely cost the insurer tens- to hundreds-of-thousands of dollars later on (or immediately)?
Does the person pre-disposed to (or currently suffering from) a serious illness have any less of a RIGHT to healthcare coverage?
Honestly, denying treatment coverage to an existing customer or flat-out denying coverage to an applicant who would certainly be a liability is no different. Either way, you’re cutting your liabilities. It might be good business, but that’s why insurance needs to be less about business and more about people.
@SkokieGuy:
Small clinical trials? I googled, as you said, and saw no evidence of clinical trials, but just a couple emails from someone who sells the stuff saying, in effect “I’ve been giving it to people, and they’re totally getting better. Really.”
A clinical trial has a control group, and is preferably double-blind. No evidence of anything of the sort. If there is, please be more specific.
@Thain: Show me where it is stated that we have a RIGHT to healthcare. I’ve read the Bill of Rights, didn’t see it in there. People simply aren’t entitled to health care.
@JustThatGuy3: Truncated from one article: … supplement designed by South African HIV and cancer crusader and researcher Marc Swanepoel had been virtually 100% successful in stabilizing and reversing HIV symptoms and over 90% successful against a broad range of cancers. As a result of this success with several hundred people over the past almost four years…….Mr. Swanepoel devised and helped conduct a small scale clinical trial….. against HIV at a well known Johannesburg AIDS clinic. The clinical trial has just concluded with results as impressive as the previous reports: All of the HIV patients improved significantly whereas all of the placebo group continued to decline. In the trial, a double blind, placebo controlled study, the 20 participants were patients attending the AIDS clinic……….
Link to article: [www.naturalnews.com]
So they are using the classic scientific standard, but (I am guessing due to a miniscule budget) did the test on an extremely small sample size. Regardless, this certainly seems like promising data worthy of further research. As far as I’m aware, it’s not even getting (mainstream) media play, let alone any funding or research from traditional medicine sources (drug companies, government or universities).
Wow, a little late to this, but let me just add my 2 cents
“Scientific funding costs money. Most funding sources are either the government (owned by corporate lobbyists), or private drug companies.”
I work at the NIH as a scientist and I know for a fact that corporate lobbyists have ZERO say in what we research. And while we’re on the point of conspiracy theories,
“The U.S. public spent an estimated $36 billion to $47 billion on complementary and alternative medicine (CAM) therapies in 1997.” (from nccam.nih.gov). That’s a lot of money. CAM is big business, and is a worry when much of it was not been shown to offer any real benefit other than as a placebo. In fact I could link you many studies showing negative effects of CAM:
[www.maj.com]“> hepatotoxicity_of_herbal_remedies.pdf
“Prove to me that alternative medicine IS getting research funding!”
The fact is that CAM is getting funding, just check out [nccam.nih.gov]“>NCCAM
But you’re obvoisily a CAM true believer so there’s nothing I can really say that would influcence you and your conspiracy theories. Sure there are some things wrong with the FDA at the moment, but nothing even close to what you’re ranting about.
@HIV 2 Elway: “We’re not comparing the same things.”
That would be your problem, not mine.
@HIV 2 Elway: “You’re talking about not honoring coverage already extended to a customer.”
Yes, I am. I’m pleased that you caught that.
@HIV 2 Elway: “That’s bogus.”
Yes, it is. I’m pleased that you agree.
@HIV 2 Elway: “I’m talking about not insuring a high risk customer in the first place.”
I wasn’t *responding* to that. If a company doesn’t feel like extending coverage, that’s their lookout. But that’s not the point of this thread and it certainly isn’t what I was talking about.
@HIV 2 Elway: “If a policy is granted, it needs to be honored.”
Yes, it does. I’m pleased that we agree on that point.
@HIV 2 Elway: “However, it’s unrealistic to think that insurers should have to insure anyone who applies.”
Yes, it would be. And of course you noticed that I made no comment about that, right?
Wow, a little late to this, but let me just add my 2 cents
@SkokieGuy: “Scientific funding costs money. Most funding sources are either the government (owned by corporate lobbyists), or private drug companies.”
I work at the NIH as a scientist and I know for a fact that corporate lobbyists have ZERO say in what we research. And while we’re on the point of conspiracy theories,
“The U.S. public spent an estimated $36 billion to $47 billion on complementary and alternative medicine (CAM) therapies in 1997.” (from the national center for complementary and alterative medicine) and this figure is bound to have grown by quite a lot since then. That’s a lot of money, so much it’s becoming a little tiring hearing how CAM is the little guy fighting against the big money.
CAM is big business, and it’s a worry when much of it was not been shown to offer any real benefit other than as a placebo. In fact I could link you many studies showing negative effects of CAM:
[www.maj.com]“> hepatotoxicity_of_herbal_remedies.pdf
But then I guess these studies are from corporate stooges (rolls eyes).
@SkokieGuy: “Prove to me that alternative medicine IS getting research funding!”
The fact is that CAM is getting funding, just check out [nccam.nih.gov]“>NCCAM
But you’re obviously a CAM true believer so there’s nothing I can really say that would influence you and your conspiracy theories. Sure, I think there are some things wrong with the FDA at the moment, but nothing even close to what you’re ranting about.
@HIV 2 Elway: “Show me where it is stated that we have a RIGHT to healthcare. I’ve read the Bill of Rights, didn’t see it in there.”
While I am in no way asserting a right to health care, you clearly missed the Ninth Amendment:
“The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.”
[en.wikipedia.org]
Given that, perhaps you could show me where in the Constitution businesses are guaranteed a profit.
@HIV 2 Elway: “People simply aren’t entitled to health care.”
Nor are businesses entitled to profit.
Wow, a little late to this, but let me just add my 2 cents
@SkokieGuy: “Scientific funding costs money. Most funding sources are either the government (owned by corporate lobbyists), or private drug companies.”
I work at the NIH as a scientist and I know for a fact that corporate lobbyists have ZERO say in what we research. And while we’re on the point of conspiracy theories:
“The U.S. public spent an estimated $36 billion to $47 billion on complementary and alternative medicine (CAM) therapies in 1997.” (from the national center for complementary and alterative medicine) and this figure is bound to have grown by quite a lot since then.
That’s quite a lot of money, so much it’s becoming quite tiring hearing how CAM is the little guy fighting against the big money.
CAM is big business, and it’s a worry when much of it was not been shown to offer any real benefit other than as a placebo. In fact I could link you many studies showing negative effects of CAM: hepatotoxicity_of_herbal_remedies.pdf
But then I guess these studies are all from corporate stooges (rolls eyes).
@SkokieGuy: “Prove to me that alternative medicine IS getting research funding!”
The fact is that CAM is getting funding, just check out NCCAM.
But you’re obviously a CAM true believer so there’s nothing I can really say that would influence you and your conspiracy theories. Sure, I think there are some things wrong with the FDA at the moment, but nothing even close to what you’re ranting about.
@BigElectricCat: No one has suggested the companies are entitiled to profit. Rather, what is being suggested, is that companies be free to opporate how they choose in a manner that allows them to maximize their interests.
No, there’s no “right” to health care, just as there’s no “right” to roads, or schools, or any of the other things that wouldn’t be accessible to poor people if we had a pure market system in every industry. Society has made a choice that these are desired public goods to which all people should have access. The insurance system provides perverse incentives, I agree. But let’s not drag the Constitution into this. It comes down to a difference in political beliefs. Some people think the government should have an expanded role; others, a contracted role. That’s all fine and good. What I implore you to remember is that our current system, as a commenter noted above, works to encourage care only for healthy people and to deny care for unhealthy people. I believe this is a serious problem. No, there’s no “right” to health care, but if society as a whole decides that it is a desirable good, government intervention is warranted, especially when the existing private market system is so clearly inadequate to meet people’s needs.
@HIV 2 Elway: “No one has suggested the companies are entitiled to profit. Rather, what is being suggested, is that companies be free to opporate how they choose in a manner that allows them to maximize their interests.”
I took your snarky comment in re the right to healthcare as deserving of a snarky comment right back in re the right to profit.
Perhaps you would show us where all these putative business freedoms to which you allude are enshrined in our precious Constitution?
@HIV 2 Elway: You just post to stir up a shit storm, right?
“I guess that’s one of the perks of taking control of ones life, educating yourself and find ample employment.”
Dude, should rewrite this to say “I guess that’s one of the perks of taking control of ones life, educating yourself and find ample employment, and never getting screwed over by the random viscitudes of life’s uncertanity inflicted on the average working stiff when living in a capitalist oligarchy.”
There are a ton of big, tough questions about the right way to run a health care system. The bottom line is that if everyone is entitled to bleeding edge, mayo clinic style care, the country goes bankrupt, and quick, but trying to make a decision about who gets treated when the result is literally life and death take King Solomon’s wisdom to get right. But in all these really, really tough issues, one is really easy: the people in charge of making these life and death decisions shouldn’t have corporate profits as their ultimate duty. I mean, fuckin’ duh. Now that we’ve solved that, we can get rid of the private insurance companies and then start working all the hard bio-ethical issues of modern health care.
Forgot to mention step #6:
Find the top five corporate officers of the insurance company (use the annual reports from http://www.edgar.sec.gov, you want the 10-k filing). Then start killing their families. Maybe start with their pets, if it’s a non-life threatening condition, otherwise, I’d start with their kids.
Wow, a little late to this, but let me just add my 2 cents
@SkokieGuy: “Scientific funding costs money. Most funding sources are either the government (owned by corporate lobbyists), or private drug companies.”
I work at the NIH as a scientist and I know for a fact that corporate lobbyists have ZERO say in what we research. And while we’re on the point of conspiracy theories:
“The U.S. public spent an estimated $36 billion to $47 billion on complementary and alternative medicine (CAM) therapies in 1997.” (from the national center for complementary and alterative medicine) and this figure is bound to have grown by quite a lot since then.
That’s quite a lot, so much it’s becoming quite tiring hearing how CAM is the little guy fighting against the big money.
CAM is big business, and it’s a worry when much of it was not been shown to offer any real benefit other than as a placebo. In fact I could link you many studies showing negative effects of CAM: hepatotoxicity_of_herbal_remedies.pdf
But then I guess these studies are all from corporate stooges (rolls eyes).
@SkokieGuy: “Prove to me that alternative medicine IS getting research funding!”
The fact is that CAM is getting funding, just check out NCCAM.
But you’re obviously a CAM true believer so there’s nothing I can really say that would influence you and your conspiracy theories. Sure, I think there are some things wrong with the FDA at the moment, but nothing even close to what you’re ranting about.
3b is what saved us. This was because of a scammy doctor that would apply to be a member of a particular insurance plan only to not complete the application. This would have him listed as a participating member for 30 days at a time. If only we had know to ask about recent changes in status for that doctor, that would have saved us more than a year of trouble. In the end the insurance paid because of this and they were supposed to sue him but we had to sign documents that we would not sue the insurance company, the doctor, the clinic, and/or the hospital.
Aetna seems to be taking lessons from United Healthcare on this front!
They have tried claiming my primary is not in network, when she is in fact listed on their website as being in-network. They have tried denying my claims for physical therapy by stating that even though we were covered by their PPO and only needed to pay the co-payment, we were also liable for a $10 to $20 charge per visit. They claim that this is because they only pay 90 % of what is left after the co-pay. None of this is listed in the policy documentation. We’re still battling this and it may well end in small-claims court.
Every time we need a doctor, be it for a routine office visit or an all-out emergency, Aetna has been trying to rip us off.
It becomes much harder, because both my hubby and I are unemployed – we’re paying for Cobra. The moment one of us has a full-time job, we’re switching.