When an insurance claim is rejected it is best to stay calm and research the reason of the rejection, though this may require a lot of patience, you have a 50% chance of saving thousands of dollars in medical bills. First of all research why your claim was rejected and ask for an explanation, keeping records of when and whom you spoke to. "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. Learn the entire appeal process along with deadlines as a missed deadline can negate your appeal.
At times the cause for rejection can be something as simple as a clerical error, like a wrong code being used for your medical procedure. This can be clarified with a few calls to your health providers billing office.
AdvertisementWrite a letter with all the points clearly highlighted as to why your claim should have been honored. Your doctor can offer his input on this. A physician can attest as to why the care you needed was medically necessary and all other alternatives had been exhausted. Support the doctor's theory with all medical records - even confidential ones. Try to include articles from medical journals which will add support to your claim. You can use the National Institutes of Health website www.pubmed.gov to search journals around the world.
The insurer's reasons for denying your claim have to be directly addressed - this is important. All correspondence should be sent by certified mail so that you can document the dates and deadlines which can prove or lose your claim. Do not give up, be persistent. The insurer may allow a peer-to-peer review in which your doctor can meet the physician appointed by the insurer.
Some people with employer sponsored health insurance can ask the company for help. Large companies with more than 200 workers usually pay the medical bills and insurers are hired to manage their plans. When the employer refuses to overturn the insurer's decision, it is important for companies to be brought into the appeals conversation so they can consider making coverage adjustments over time.
The human resources department can check to see if your coverage is self-funded help you understand the procedure for an appeal. 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.
Tom Murphy, August 2014
Hannah Punitha (IRDA Licence Number: 2710062)