HOW TO FIGHT YOUR INSURER ... AND WIN
by Nancy Davenport-Ennis

Don't throw up your hands if your health insurance company denies a claim. There are ways to fight back...

HEALTH INSURANCE

More than half of all Americans will have a disagreement with their medical insurers some day:
Problems often develop when you're not able to use a specific health-care provider, or obtain approval for a specific treatment, or when a bill is "kicked back" - unpaid - from the insurance company after treatment.

When a claim is denied, the patient's health-care provider normally handles he first stage of the appeals process. If he appeal is rejected, the patient needs to play an active role in further appeals.

Find out why the claim was rejected. It is usually because...

• The treatment was not preauthorized, as required by the plan.
• The claim was coded incorrectly by the provider.
• The insurance company believes the treatment was not medically necessary:
  
  • The insurance company regards the treatment as experimental.
  • The insurance plan specifically excludes that treatment
  • The health-care provider is not included in the plan.

If you did not receive written notice of the denial, call the insurance company and request one. Without such documentation, you will have no foundation for an appeal.

Get a copy of your actual health insurance policy.
An estimated 40% of people facing rejected claims do not have this document. Request a copy from your employer's human resources department.

Enlist help.
With the written denial and health plan documents in hand, it is time to seek professional help. Our nonprofit organization can provide references (800-532-5274)...or check our Web site for a list of resources in your region (http://data.patientadvocate.org).

Keep an eye on the calendar.
Every insurance policy has a limited window for filing appeals, generally 30 to 90 days from the date of rejection. After the deadline, it becomes substantially more difficult -or even impossible- to appeal.

Address the reason for the insurer's rejection in your appeal.

• If the insurer says a procedure is medically unnecessary - find statistics showing the procedure may extend or improve quality of life. Also provide encouraging statistics from clinical trials.
• If the insurer claims that a medical procedure is experimental- you, your health-care provider or your lawyer must prove otherwise, by citing studies on the subject published in well-regarded, peer-reviewed medical journals. Enlist the help of your health-care provider.
• If the insurer excludes the procedure-file a compassionate appeal and cite the facts to support exceptions. Important: Doctors' appeals of rejected claims are most likely to fail when they focus on medical ethics and opinion and neglect what the insurance companies like - hard proof.

About the author:
Nancy Davenport-Ennis, founding executive director of Patient Advocate Foundation, a nonprofit organization that acts as a liaison between patients and their insurers and provides insurance counseling to consumers, 753 Thimble Shoals Blvd. Ste. B, Newport News, Virginia 23606. www.patientadvocate.org. This organization publishes two books on insurance, The Managed Care Answer Guide and Your Guide to the Appeals Process.

This article is posted on our web site with the friendly permission of the Patient Advocate Foundation. Thank you!

Julian Credit Management is a firm that practices exclusively in the area of Bankruptcy and Debt Consolidation and has offices in Clearwater (Pinellas County), Port Richey (Pasco County), Tampa (Hillsborough County), Lakeland (Polk County) and Orlando (Orange County). We represent persons throughout the State of Florida.

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