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SolveYourProblem
Article Series:
Health Insurance
Fighting
an Unfair Health Insurance Claim
Are
you having trouble getting your insurance company to pay
your medical health costs? Join the club. When
managed care entered the insurance scene a decade ago, its
mandate was to contain rising medical costs. One way to do
that is to deny claims, even when claims are legitimate. The
consumer backlash led to many states establishing independent
review panels and requiring insurance companies to develop
in-house appeal procedures. Forty-two states now have independent
review boards whose decisions can override those of insurance
companies. Most consumers don’t even realize these review boards
exist.
Another problem is that too many people just give up when
their insurance claim is denied initially. The appeals process
can be long and frustrating and many people don’t have the
patience or time to pursue a claim no matter how legitimate.
People must be persistent and they can win. Particularly if
there’s substantial money involved, the time you dedicate to
appealing insurance company decisions can pay off usually more
quickly than you think. A Kaiser Family Foundation study recently
found that 52% of patients won their first appeal for each
claim made. The insurance companies aren’t getting with out
paying anymore.
If
your first appeal gets turned down, press on. The study
found that those who appealed a second time won 44% of the
time. Those who appealed a third time won in 45% of cases.
Which means the odds are in your favor no matter how long it
take. Remember that every time you appeal it costs the insurance
company more money to fight you and they are not only going
to lose money to you, but also in court costs. Medical health
benefits are particularly tricky because insurance companies
usually have a cap on the amount of money they’ll spend in
a given year, or on the amount of visits they’ll pay for. But
there’s often some flexibility when you can document that you
or your child’s health warrants more care than your policy
usually covers. Here’s how to get started:
Do Your Homework
Read
your Policy: What are the benefits? Which kinds of services
are included? Outpatient or inpatient care? Is it a serious
or “non-serious” diagnosis?
Know
the law: Contact your local Health Association to determine
your states legal requirements regarding insurance payments
for all illness. Does your state require full or partial parity?
Are parity benefits available only to patients with “Serious
Illness” or is a so-called non-serious illness also included?
Provide
written documentation: Some insurance companies may
not consider some diagnosis’s serious. In this case, you will
need documentation to validate required services. Obtain a
letter of medical necessity from your doctor and get test results
showing the medical need for you or your child to receive certain
services, based on the diagnosis.
Keep
good records: Remember, you’ll be dealing with a bureaucracy.
Keep the names and numbers of everyone with whom you speak,
the dates on which you spoke, and what transpired in the conversation.
Start
early: If you can, start the appeals process prior to
initiating treatment. If the doctor says your child will need
to be seen once a week for a year, begin immediately to appeal
your insurance company’s policy of reimbursing only 20 visits
a year.
Call and Ask the Insurance Company:
- What are the prerequisites for receiving health benefits?
- How many visits are allowed annually for you or your child’s
diagnosis? Can multiple services be combined on one day and
be counted as only one day or one visit?
- Which services must be pre-certified--by whom?
Be positive, polite and patient with the customer service
representative. Remember that he/she is only the messenger,
not the decision-maker. They are the gatekeepers and can either
provide you with access to a decision maker or make your life
miserable, depending on how you interact with them.
Be persistent. There are no magic bullets. Be like a dog with
a bone and don’t give up until you get the answer you want.
If you get nowhere after several calls, ask for a supervisor
or a nurse in the pre-certification department.
Remember that you do have the right to appeal if your claim
is denied. Most consumers get discouraged and will not continue
to pursue a claim that should or could be paid. Insurance companies
count on that happening, so get out there and claim what’s
justifiably belong to you.
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SolveYourProblem.com
: 2006
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