IIf there's anything worse than being sick, it's being sick while dealing with insurance issues. But unfortunately, this situation is all too common. Recent research The Commonwealth Fund, a private foundation that researches health issues, found that 17% of American adults had their insurance companies deny them doctor-recommended medical care in the past year, with denials occurring at about the same rate among people with commercial and government insurance plans.
Denials can occur either before you’ve had a test, procedure, or treatment — such as when a provider requests prior authorization — or after you’ve already received care. An insurer may argue that a service isn’t covered or is medically unnecessary for you, or it may deny care for logistical reasons, such as if the claim contains incorrect information or comes from an out-of-network provider.
Receiving a rejection letter can be discouraging, but there are steps you can take to fight back. Here's what to do.
Read your rejection letter in its entirety.
“It’s easy to be tempted when you see an email full of jargon, but it’s important to read it carefully,” says Jeremy Gurewitz, CEO of ComfortA company that connects consumers with advocates who help them navigate the health care system. Your letter should clearly state why you were denied coverage, and that reason is important, Gurewitz says, because it determines what you can do next. Your problem may have a simple solution, such as providing additional documentation or refiling your claim with different information. Or it may require filing an appeal to prove that your doctor’s treatment plan is, in fact, medically necessary. Gurewitz recommends starting with a call to your insurer’s customer service line, since some issues can be resolved over the phone.
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Insurance companies also make mistakes “all the time,” Gurewitz says, so don’t assume your denial letter is correct and give up. Check your insurance documents to make sure what the insurer says is true, and ask them to correct any errors you find.
Address
Even if your denial can't be easily reversed—for example, if the company says the service isn't medically necessary, or you accidentally go to an out-of-network provider—you still have options.
“Never take no for an answer, ever,” says Wendell Potter, a former Cigna executive who became a whistleblower and advocate for health reform after leaving the company in 2008. “Insurance companies expect people enrolled in their health plans to just accept whatever they decide to do because [pushing back] It's difficult. It's a burden. It's routine..”
However, people who take the time to appeal often achieve good results. A recent Commonwealth Fund report found that half of people who challenged insurance denials ended up getting at least a partial approval or approval for a similar service. (The same applies to medical billsBy the way. Recent research (It is estimated that more than 60% of people who try to negotiate their medical bills are successful in getting a price adjustment.)
But crafting a good appeal requires some homework. First, go back to your denial letter, which should include information on how to appeal and possibly specific instructions on what to include and in what format, Gurewitz says. This information should also be available on your insurer's website.
If you’ve been denied on medical grounds, your goal is to make a clear and compelling case for why you need the treatment, procedure, or drug. If you can, involve your doctor, recommends Diane Spicer, a senior attorney at Community Health Advocates (CHA), a group that helps people in New York navigate the health care system. This can be difficult because providers aren’t always willing or able to make the time, she says. But if your doctor makes a detailed case for medical necessity, backed up by medical records and clinical notes, that significantly strengthens your case, she says.
Your doctor may decide to write the letter themselves or provide you with a statement that you can include in your own letter. You can also search the Internet for a strong letter template and send it to your doctor as an example.
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You also have the right to request the criteria your insurer used to make its decision, Spicer says. The best way to get this, as well as other records related to your case, is to request your “claim file.” You can compare the insurer's decision criteria with national standards of care for your condition; if your insurer tries to apply a stricter standard than usual, you can include this information in your appeal letter.
To find these national standards, Spicer recommends using a search term like “Guidelines for the diagnosis, management, and treatment of [insert name of condition, being as specific as possible].” Search results will usually lead you to reports or recommendations from national health organizations. You can also search Until nowa database that collects information about evidence-based practices in health care, but for which a fee is charged.
If you were denied because you received treatment from an out-of-network provider, you can also appeal, Spicer says. The Law of No Surprises protects consumers in a variety of circumstances, such as if you are treated by an out-of-network doctor during an emergency or a provider erroneously listed as in-network in the insurer's database.
Insurers often ask that appeals be sent by mail. If so, it’s “crucial” to send them certified mail so that delivery can be tracked, Gurewitz says. “You want to have a paper trail,” he says.
Escalation
If your appeal is rejected, it's not the end of the road. If the company continues to stand by its original decision, you can request external review in which a third party evaluates the case.
Potter also says you don’t have to stop at filing an appeal through official channels. Consider alerting insurance executives, regulators, local politicians, or the media to ramp up the pressure. Potter acknowledges that this works best if you have a particularly sympathetic or dramatic story — for example, if the company’s denial has caused you to delay emergency care or caused significant financial hardship. If you don’t want to go that far, you can always reach out to the company on social media, Potter says.
“Being the squeaky wheel is important,” Potter says. When he worked at Cigna, he says, the company had a system for dealing with “high-profile” cases, such as those that caught the attention of a journalist. “Soon,” he says, “that denial will be overturned.”
Get help
If all this seems overwhelming, turn to the experts. Health advocates can help craft a compelling appeal because they know the ins and outs of the system and what has worked for specific insurers in the past.
Consumers can work with health professionals, whose services are often free, through private companies such as Comfortcharities such as Patient Advocate Foundationor government organizations like CHA. Sometimes employers even offer health care as a benefit to employees. Coming soon to the startup Claimed It also promises to use artificial intelligence to sort through medical tests, information about your insurance plan and medical history, and data from past appeals to create a more effective plan.
Whatever path you choose, it’s important to remember that there are people who can help, Gurewitz says. “When you or a loved one is dealing with a serious illness,” he says, “the last thing you want to do is dig through paperwork.”