Friday, February 27, 2015
FAIRFIELD-SUISUN, CALIFORNIA
99 CENTS

On the money: 4 keys to appealing a rejected insurance claim

Medicaid Hospitals

In this photo taken Thursday, July 10, 2014 a patient is assisted at Southeastern Regional Medical Center in Lumberton, N.C. Rural community hospitals like Southeastern Regional are struggling to stay afloat amid a backlog of unpaid Medicaid claims, a shrinking reimbursement rate, and more carve-outs of services covered. (AP Photo/Gerry Broome)

By
From page B7 | August 24, 2014 |

Tom Murphy

Keep calm and take notes.

Stay true to this principle and you can improve your odds of successfully fighting a health insurer’s claim rejection.

Experts who help with the appeals process say patients have a 50 percent chance or better of prevailing. They say a winning argument may require heavy doses of research and persistence, but the end result is a decision that can stave off thousands of dollars in medical bills.

Certainly understanding the limits of your insurance, before you seek care, will help you avoid the frustration of having your claim denied. But if you get to the point where you need to appeal, here are some important points to remember.

Starting an appeal

Learn all you can about why your claim was rejected and don’t be afraid to ask questions. If the insurer deems your care to be not medically necessary, request an explanation that includes the insurer’s policy language and any information used in making the decision. Keep records of who you spoke with and when.

“Take down notes and get the language down as cleanly as possible,” said Stephen Parente, a professor of health finance and insurance at the University of Minnesota.

Maintaining a calm demeanor can help you think rationally, and it may make customer service representatives more inclined to help.

Learn the insurer’s appeal process, including any deadlines. A missed deadline can sink an appeal regardless of how strong your case is.

Building your case

Sometimes a claim is denied due to a clerical error, such as the wrong code being used for a medical procedure. A good starting point is to check with your provider’s billing office to make sure your claim was coded correctly. If something is amiss, you can probably get it cleared up with a few phone calls.

Other cases may require an appeal letter. Your letter should lay out the reasons you believe your care should be covered. Ask your doctor to review your argument and offer input.

A physician can help detail how all treatment alternatives were exhausted before you started receiving the care an insurer deemed not medically necessary.

The insurer will want more than your doctor’s word, so be prepared to include any confidential medical records that support your case.

Consider including medical journal articles that support your argument or detail the effectiveness of your treatment. These can be especially helpful if your doctor is unable or unwilling to work with you on the appeal. Patients can use the National Institutes of Health website www.pubmed.gov to search journals around the world.

Make sure you directly address the insurer’s reason for denying coverage. Not doing so is the biggest mistake people make in filing appeals, according to Cheryl Fish-Parcham, private insurance program director for the health advocacy group Families USA.

Submit your appeals by certified mail so you can document when the insurer receives them and that you met any specified deadlines.

Be persistent. If the first appeal doesn’t work, the insurer should outline additional options that may include an appeal to a medical director who was not involved in the decision.

The insurer also may permit a peer-to-peer review, in which your doctor talks to a physician representing the insurer about your case.

Going outside the insurer

If you’re not happy with the insurer’s internal review, seek an examination from an independent reviewer. Be mindful of any deadlines for making such a request.

Some patients with employer-sponsored health plans also may be able to turn to their company for help. Companies with self-funded coverage — largely those with 200 or more workers — actually pay the medical bills and hire insurers to administer their plans.

The employer may learn through your appeal that its coverage is more limited than what company leaders intended, said Erin Moaratty, chief of mission delivery for the Patient Advocate Foundation, a nonprofit organization that helps patients with medical bills and coverage denials.

Even if the employer declines to overturn the insurer’s decision, it can be important for companies to be brought into the appeals conversation so that they can consider making coverage adjustments over time.

Check with your human resources department to see if your coverage is self-funded and if they can help you understand the appeals process or put you in touch with the right insurance representative.

Seeking help

If you’re not comfortable shaping your argument, or you’re not physically up to it, you have a few options for outside help. Some states offer consumer assistance programs, and your insurer should provide you with contact information for the program in your state.

Help is also available from nonprofit agencies like Patient Advocate Foundation and The Jennifer Jaff Center, which can assist with appeals in cases involving chronic, life-threatening or debilitating illnesses.

For-profit companies like Medical Billing Advocates of America also work on insurance denials. A spokeswoman said its fees depend on the amount of time spent working on the case.

 

The Associated Press

The Associated Press

LEAVE A COMMENT

Discussion | No comments

The Daily Republic does not necessarily condone the comments here, nor does it review every post. Read our full policy

  • Recent Articles

  • Enter your email address to subscribe and receive notifications of new posts by email.

  • .

    Solano News

     
    Fairfield mayor ready to share a whale of a tale

    By Amy Maginnis-Honey | From Page: B1

     
    Oakland author, vet talks about researching Vietnamese side of war

    By Ian Thompson | From Page: A1 | Gallery

    Nonagenarian recounts life as spy in World War II

    By Amy Maginnis-Honey | From Page: B1

     
     
    Republican women to hear about immigration reform

    By Amy Maginnis-Honey | From Page: A3, 1 Comment

     
    2-day event will focus on bullying prevention

    By Amy Maginnis-Honey | From Page: A3

     
    Kaiser offers Capoot scholarships

    By Bill Hicks | From Page: A4

     
    Wolk to chair committee on state’s wine industry

    By Kevin W. Green | From Page: A4

     
    Suisun City police log: Feb. 25, 2015

    By Susan Hiland | From Page: A12

     
    Fairfield police log: Feb. 25, 2015

    By Susan Hiland | From Page: A12

    .

    US / World

    Llamas on the loose trends on Twitter

    By The Associated Press | From Page: A2

     
    Two inured in hazmat explosion

    By The Associated Press | From Page: A4

    No charges yet for train crash truck driver

    By The Associated Press | From Page: A4

     
    Sacramento man pressured to remove swastikas

    By The Associated Press | From Page: A5, 1 Comment

    Not guilty plea for suspect in Hollywood exec murder

    By The Associated Press | From Page: A5

     
    After 67 years of marriage, couple dies holding hands

    By The Associated Press | From Page: A5

     
    Missing 400-year-old Italian books found in California

    By The Associated Press | From Page: A5

    Feds: 3 accused in Islamic State plot vocal about beliefs

    By The Associated Press | From Page: A6

     
    Saudi man convicted of conspiracy in ’98 US embassy bombings

    By The Associated Press | From Page: A7

     
    Panel: Use new meningitis vaccines only for outbreaks

    By The Associated Press | From Page: A7

     
    House GOP weighs new approach on Homeland Security

    By The Associated Press | From Page: A7

    Vandalism in Arizona shows the Internet’s vulnerability

    By The Associated Press | From Page: A7

     
    Prosecutor: Mom craved attention, poisoned child with salt

    By The Associated Press | From Page: A7

    Ukraine, rebels start pulling back heavy weapons in the east

    By The Associated Press | From Page: A10

     
    ‘Jihadi John’ raised in UK, studied computers, reports say

    By The Associated Press | From Page: A10

    Militants abduct more Christians, smash ancient artifacts

    By The Associated Press | From Page: A10

     
    .

    Living

    Today in History: Feb. 27, 2015

    By The Associated Press | From Page: A2

     
    Community Calendar: Feb. 27, 2015

    By Susan Hiland | From Page: A2

    Horoscopes: Feb. 27, 2015

    By Holiday Mathis | From Page: A9

     
    I’m worrie about how my wife’s erratic behavior is affecting our kids

    By Kathy Mitchell and Marcy Sugar | From Page: A9

    .

    Entertainment

    Week in preview Feb. 27-March 5, 2015

    By Amy Maginnis-Honey | From Page: B1

     
    Review: Smith, Robbie pour on the charm in sharp ‘Focus’

    By The Associated Press | From Page: B2

    Custom dress Lupita Nyong’o wore at Oscars reported stolen

    By The Associated Press | From Page: B2

     
    Conan O’Brien takes his show to Cuba for a special hour

    By The Associated Press | From Page: B2

    ABC’s Sawyer does prime-time prison special

    By The Associated Press | From Page: B3

     
    Q&A: Writer-director-actor Mark Duplass is a busy guy

    By The Associated Press | From Page: B3

    Actor Will Patton charged with DUI in native South Carolina

    By The Associated Press | From Page: B3

     
    AP Exclusive: Redmayne lends voice to “Thomas & Friends”

    By The Associated Press | From Page: B3

    Entertainment Calendar: Feb. 27, 2015

    By Susan Hiland | From Page: B4

     
    Tea Leoni in a happy state as star of ‘Madam Secretary’

    By The Associated Press | From Page: B5

    Graceland brings Elvis back to his Las Vegas home

    By The Associated Press | From Page: B6

     
    TVGrid

    By Daily Republic Syndicated Content | From Page: B6

    .

    Sports

    A’s begin baseball’s mandatory domestic violence training

    By The Associated Press | From Page: B7

     
    Earthquakes set to open new MLS stadium

    By The Associated Press | From Page: B7

    LeBron scores 42, Cavs beat Warriors for 18th win in last 20

    By The Associated Press | From Page: B7

     
     
    NASCAR back on track for extra day of testing in Atlanta

    By The Associated Press | From Page: B8

    No word on possible MLB discipline for Angels star Hamilton

    By The Associated Press | From Page: B8

     
    Giants closer Casilla hit on shin during batting practice

    By The Associated Press | From Page: B8

    LeBron not happy colleges recruiting 10-year-old son

    By The Associated Press | From Page: B8

     
    IOC member, once critical of Rio, now sees ‘great progress’

    By The Associated Press | From Page: B8

    Judge rules for Peterson, opening door for reinstatement

    By The Associated Press | From Page: B8

     
    Herman survives windy day; McIlroy stumbles at Honda Classic

    By The Associated Press | From Page: B8

    Roberts, NBA writers open discussion over locker room access

    By The Associated Press | From Page: B8

     
    IOC relaxes rule on athletes and sponsors during Olympics

    By The Associated Press | From Page: B8

    Nevada gambling regulators sign off on Olympic betting

    By The Associated Press | From Page: B8

     
    Video shows Hernandez dancing near gas pump before killing

    By The Associated Press | From Page: B8

    Kings’ Collison to have surgery, re-evaluated in 3-6 weeks

    By The Associated Press | From Page: B8

     
    AP source: 49ers to bid to host college football title game

    By The Associated Press | From Page: B8

     
    Bulls say Rose to have surgery on Friday

    By The Associated Press | From Page: B8

    .

    Business

    Volkswagen Jetta is a pleasure to live with, not just to gawk at

    By Washington Post | From Page: C1 | Gallery

     
    5 things to know about ‘net neutrality’

    By The Associated Press | From Page: A1

    Regulators approve tougher rules for Internet providers

    By The Associated Press | From Page: A1

     
    Strong reliability scores should help Buick brand’s rebirth

    By The Associated Press | From Page: C2

    Nissan executive known as ‘father of the Z’ dies at 105

    By The Associated Press | From Page: C2

     
    Medical marijuana passes tough first hurdle in Utah

    By The Associated Press | From Page: B11

    Applications for US jobless aid rise to 313,000

    By The Associated Press | From Page: B11

     
    Google looks for more revenue from ads in Android app store

    By The Associated Press | From Page: B11

    Walmart CEO wading through mounting issues

    By The Associated Press | From Page: B11

     
    Pew study: Americans still stressed despite improved economy

    By The Associated Press | From Page: B11

    Facebook allows users to ‘fill in’ gender option

    By The Associated Press | From Page: B11

     
    .

    Obituaries

    Donald Grimm

    By Nancy Green | From Page: A4

     
    Gabriel T. Traub

    By Nancy Green | From Page: A4, 1 Comment

    Maria Kraszewski

    By Nancy Green | From Page: A4

     
    .

    Comics

    B.C.

    By Daily Republic Syndicated Content | From Page: A8

     
    Get Fuzzy

    By Daily Republic Syndicated Content | From Page: A8

    Rose is Rose

    By Daily Republic Syndicated Content | From Page: A8

     
    Wizard of Id

    By Daily Republic Syndicated Content | From Page: A8

    Zits

    By Daily Republic Syndicated Content | From Page: A8

     
    Blondie

    By Daily Republic Syndicated Content | From Page: A8

    Baldo

    By Daily Republic Syndicated Content | From Page: A8

     
    For Better or Worse

    By Daily Republic Syndicated Content | From Page: A8

    Sally Forth

    By Daily Republic Syndicated Content | From Page: A8

     
    Dilbert

    By Daily Republic Syndicated Content | From Page: A8

    Peanuts

    By Daily Republic Syndicated Content | From Page: A8

     
    Beetle Bailey

    By Daily Republic Syndicated Content | From Page: A8

    Pickles

    By Daily Republic Syndicated Content | From Page: A8

     
    Garfield

    By Daily Republic Syndicated Content | From Page: A8

    Frank and Ernest

    By Daily Republic Syndicated Content | From Page: A8

     
    Baby Blues

    By Daily Republic Syndicated Content | From Page: A8

    Cryptoquote

    By Daily Republic Syndicated Content | From Page: A9

     
    Bridge

    By Daily Republic Syndicated Content | From Page: A9

    Word Sleuth

    By Daily Republic Syndicated Content | From Page: A9

     
    Sudoku

    By Daily Republic Syndicated Content | From Page: A9

    Crossword

    By Daily Republic Syndicated Content | From Page: A9