The next step is to outline your argument for why your claim should be honored. First, read your policy carefully to determine exactly which treatments are covered and which are not. It is not uncommon for insurance companies to deny coverage for a treatment that is explicitly included under the policy.
Finding Other Help
If your doctor cant help you resolve a denied claim, there are other resources that can be tapped for assistance. If you receive health insurance from your employer, contact the human resources department and explain your predicament; some companies have a case manager who can help you make your appeal.
One of the most valuable aspects of these potential advocates is that they can help you translate your argument into the language spoken by insurance companies. The emotion and stress that patients with serious illnesses (and their families) experience when faced with a denied claim is often counterproductive when channeled into an appeal.
When appealing a denied claim, it is important to remain as calm, cool, and collected as you possibly can. As you navigate the appeals process, these tips will help you stay focused and maximize your chances of success:
- Stay organized. Keep every scrap of paper that relates to your case and have everything at your fingertips whenever you contact the insurance company. "That way you can say, line by line, 'This is what happened, this is the date, this is what I had done, this is what I was told,'" says Karie Waddell Gallo, a senior account manager at Saxon Financial Consulting of Cincinnati, Ohio, which specializes in health-insurance claims. By the same token, keep detailed notes during the conversation and write down the date and outcome of each phone call, so that you have a record you can refer back to. Knowing your policy inside and out will help you present your case well, which will force the insurer to take you seriously. If youre not sure of your facts or dates surrounding your procedures and have to scrounge around for your records, you could end up wasting a call.
- Collect names and numbers. Each time you call an insurance company representative, immediately ask for the persons name and extension. Try to deal with the same agent each time, so you dont have to repeat your whole story over and over. Ask for a reference code for your claim, so if you do have to start with a new person, he or she can access the record of prior phone conversations.
- Ask for a specific timeline. The review process for an insurance claim usually takes three to four business days. If its a major claim (more than $10,000), it may go through an additional review process with an underwriter, which can take up to 30 days, according to Gallo. Follow up with the same agent at the end of the allotted time.
- Go up the food chain. If you dont get the result you want from the person who answers your call, dont stop there. Ask to speak to someone higher up, whether its a supervisor or underwriter or the president of the company. And be persistent. "Most people only talk to the agents who sell and service the policy. Above them are the underwriters who make decisions on risk. And then there are the medical directors, the MDs who make assessments of individuals and groups," says Stewart Perry, chairman of the board of the American Diabetes Association.
Even in the face of repeated denials, determination tends to produce the best results. "In my experience, if people are asking for reasonable treatments for evidence-based medicine, the insurance company is very likely to pay if people persevere," says Dr. Brawley. "Often, if the insurance company says no, its either because they didnt understand the situation or the insurance company thought the treatment was unproven."
Perry cites the case of an Ohio woman who went to battle with her insurance company when it refused to cover diabetes testing supplies for her daughter. She took her case all the way to the president of the companywho, as it turned out, also had a daughter with diabetes. "He said, 'What do you mean we dont cover that?'" Perry recalls. In the end, the womans claim was covered.