When the CEO of United Healthcare was gunned down in broad daylight in midtown Manhattan last December, it seemed to unleash a wave of pent-up anger against health insurers from the many Americans whose claims have been denied.
Although the data varies widely by state, by type of insurance (government vs. employee sponsored) and by company, it appears that about 20% of all claims were denied by insurers in 2024. That affects a lot of your clients.
The Affordable Care Act (ACA) guarantees policyholders the right to appeal insurance denials, but few people take that route. Most appeals are unsuccessful for administrative reasons more than anything else: The appeal came too late, the insurance agreement didn’t cover a particular procedure, a prior authorization wasn’t obtained.
I’ve written before on how your clients can avoid denials, by understanding their coverage, confirming that a procedure is covered, following the rules and making sure their provider is filing promptly and providing accurate diagnostic codes.
But if your clients feel their claims for a test, procedure or particular care ordered by their doctor has been wrongly denied, how do they go about appealing? Here is some guidance to share with them.
First of all, think of your appeal as a contract dispute over the interpretation of coverage and how the language of your insurance plan defines the contract. Here is where you may want some assistance from a patient advocate — to help you understand the language and whether an appeal may be successful. If the denial is going to leave you with a bill of thousands of dollars, getting expert advice could be worth it.
Review your denial letter carefully. It must contain information on your right to file an appeal, the specific reason for the denial, detailed instructions for your appeal, key deadlines and any consumer assistance available to you. Or you can call your insurance company directly and find out how to navigate the appeals process along with any timelines you must meet.
If the hospital or doctor’s office wants you to pay the bill, let them know you’re appealing the denial and ask them to not send the bill to collections while the appeals process takes place. Work with them to compile evidence to show that the care you received was medically necessary, not experimental and covered by your health plan.
The Ins and Outs
There are two types of appeals: internal review and independent, or external, review.
In an internal review, you have up to 180 days (or about six months) to file the appeal. If you have already received the medical service, your insurer must respond within 60 days. Sometimes your well-being or even your life is contingent on getting a prompt appeal; if so, you can request an expedited process.
At the end of the internal appeals process, your insurer must provide you with a written decision. If your insurer continues to deny payment for a service — called a “final internal adverse benefit determination” — it must tell you how to request an external review.
As you might expect, most internal appeals result in the insurance company reaffirming its original decision. The external review is conducted by an organization that is unaffiliated with the insurance company and doesn’t have a financial stake in the outcome.
Recordkeeping TIps
Along the way, you can help yourself by keeping track of all your documentation, including:
All medical records relevant to the denial: Request that your doctor include their notes from your visits, important historical information and your diagnosis. This should include lab results, other tests results and notes on prior treatments. A lot of this information should be contained in your electronic medical records.
Explanations of Benefits (EOBs): These are provided by your insurance company after you have received care. They contains details including the total amount you were charged, the complete list of services provided, the amount your provider charged, the percentage your insurer will pay, and the amount you owe.
Independent medical opinions: These include second opinions you may have sought with regard to your health problem.
Copies of any correspondence with your insurance company. Include hard copy mail, denial letters, emails and notes you took while speaking with insurance representatives
Pre-authorizations: Include any documentation you submitted regarding pre-authorization or medical records releases.
Medical studies: A patient advocate can help you find professional articles that support the treatment you need or received. These articles may be particularly helpful if your insurance company claims the requested treatment is experimental.
Somewhere between 50% and 80% of insurance denials are overturned after external review. Even though it’s a frustrating process, don’t give up easily. You can find someone with experience to help you.
