Five Ground Rules For Trying To Reverse Your Health Care Denial
- Denials Happen Often – Don’t Take No For An Answer – Denials happen often, but they can be overturned with persistence and care. Do not take an initial “no” as a final answer.
- Expect Several Rounds – Reversing that first “no” can take some time and effort. Many health care insurers provide for a series of appeals. Expecting some red tape in advance will ease your frustration.
- Keep Track In Writing – As detailed in other articles, successful insurance claims often rest on the paper trail. Make a good one.
- Involve Your Doctor And Hospital – Sometimes denials will stem from medical issues beyond a layperson’s understanding, such as necessity. Your doctor or hospital might offer expert help.
- Focus On The Contract – Health care claim adjusters hear dozens if not hundreds of horrible stories involving the sick and injured. Even heart-wrenching emotional appeals may therefore have less effect than good arguments based on your precise policy terms.
Putting The Ground Rules Into Action
Keep a folder. Keep a folder with all key documents. That should include the complete copy of the plan, all denial letters, and any other emails or letters that you or the carrier sends.
The folder should also include a written log of all oral, telephone, and face-to-face meetings, with their date, time, participants, and length. Also include all promises that were made, and ask for and write down the date by which any promised action will happen. If possible, confirm any important promises and deadlines by email or letter.
Get the complete plan and denial letter. You should ask for and insist on a complete copy of your health care plan, not a written summary sheet or marketing materials. That could be what controls any later dispute. Indeed, whether your denial was proper or not will often hinge on the precise plan language. Also, get and keep copies of all denial letters. As explained below, use them together to write letters seeking coverage for your claim.
Write your first letter. Look in the plan for what benefits it promises. Compare the actual plan language to the grounds cited in your denial letters. They often do not match exactly.
Try to write an analytical letter, based on the actual plan language, explaining why the denial is wrong. If the denial letter does not cite to actual plan language, or if it inaccurately paraphrases what the plan says, point that out and include the real plan terms. Keep an even tone and avoid extra emotion.
If this does not change the decision, this often can result in a second, more detailed denial letter, which could offer more points to attack.
Involve your doctor and hospital. Call them to let them know your carrier has denied the claim. Send them the denial letter. Both doctors and hospitals often have staff who can help navigate the health care bureaucracy.
Ask them to write a letter on your behalf. It should directly refute the most recent denial letter, explain the need for this treatment if necessary, and verify that it is commonly used in your circumstances. If possible, it should also attach support such as peer-reviewed articles.
Send a second letter. Prepare a more refined second letter that responds point-by-point to the most recent denial and focuses on the plan’s language. Cite to and include your doctor’s letter. Copy them both, and send them to your carrier.
Appeal any further denial. At this point, you may be referred to a panel of doctors. Make sure they are all specialists in the relevant treatment area – if they are not, you should consider protesting the panel make-up. Ask if you can make a personal presentation to the panel, whether by phone or otherwise, and see if your doctor can join in, too.
Seek help from an attorney. At this point, if your appeal is denied, you will likely need to sue to recover, and that could require an attorney. (Insurance regulators in some states also have an independent appeal process that might also be available.) Indeed, you should consider using an attorney earlier if you can afford it. They typically have more experience at analyzing contract language (your plan is a contract), drafting written arguments, and making oral presentations. But if possible, make sure they have health care experience.
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John J. Rasmussen founded the Insurance Recovery Law Group, PLC after nearly a decade of working for insurance companies. You can learn more about him and his practice at www.insurance-recovery.com. You can contact him at jjr@insurance-recovery.com.