If there’s anything worse than being sick, it’s being sick while dealing with insurance issues. But unfortunately, that situation is very common. Recent research From the Commonwealth Fund, a private foundation that researches health care issues, it finds that 17% of U.S. Adults were denied doctor-recommended care by their insurance company, a frequent denial for people on both commercial and government insurance. Plans
A denial can happen either before you receive a test, procedure, or treatment—when a provider submits a request for prior authorization, for example—or after you’ve already received care. The insurer may argue that the service is not covered or is medically unnecessary for you, or it may deny care on logistical grounds, such as a claim with incorrect information or a claim from an out-of-network provider.
Receiving a rejection letter can be frustrating, but there are certain steps you can take to fight back. Here’s what to do.
Read your rejection letter in its entirety
It’s easy to let your eyes glaze over when faced with a jargon-filled letter, but it’s important to read it carefully, says Jeremy Gurewitz, CEO of ConsolationA company that connects consumers with advocates who help them navigate the health care system. Your letter should spell out exactly why you were denied coverage—and knowing that reason is important, Gurewitz says, because it determines your next steps. There may be a fairly straightforward solution to your problem, such as providing additional paperwork or resubmitting the claim with different information. Or, you may need to appeal to argue that your doctor’s treatment plan is, in fact, medically necessary. Gurewitz recommends starting with a call to your insurer’s customer service line, as some issues can be resolved over the phone.
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Even insurance companies make mistakes “all the time,” Gurewitz says, so don’t assume your denial letter is correct and give up right away. Consult your policy documents to verify that what the insurer claims is correct and ask them to correct any errors you find.
appeal
If your denial can’t be easily reversed—such as when the company argues that the service isn’t medically necessary, or you accidentally see an out-of-network provider—you still have options.
“Never take ‘no’ as the final answer,” says Wendell Potter, a former Cigna executive who became a whistleblower and healthcare reform advocate after leaving the company in 2008. Because they plan to accept what they decide to do [pushing back] is complicated. It is a burden. It’s a chore“
However, people who take the time to appeal often get better results. A recent Commonwealth Fund report found that half of those who challenged insurance denials ultimately received at least partial approval or approval for the same service. (The same is true for Medical billsBy the way. Recent research (suggests that more than 60% of people who try to negotiate their health bills successfully get a price adjustment.)
However, making a good appeal requires doing some homework. First, refer to your denial letter, which should include information about how to file an appeal and, potentially, specific instructions about 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 the grounds of medical necessity, your goal is to make a clear, compelling case why you need the treatment, procedure, or drug. If you can, get your doctor involved, recommends Diane Spicer, supervising attorney for Community Health Advocates (CHA), which helps people navigate the health care system in New York. 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 argument for medical necessity through medical records and clinical notes, that strengthens your case significantly, she says.
The doctor may choose to write a letter himself or he may provide you with a statement to include in your own letter. You can also find a strong template letter online and send it to your doctor as an example.
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Spicer says you’re also entitled to ask what criteria your insurer used to make its decision. The best way to get these, as well as other records related to your case, is to ask for them yourself.File a claim” You can compare the insurer’s decision-making criteria to the national standard of care for your condition; if your insurer is trying to apply a stricter standard than usual, you can include that information in your appeal letter.
To find these national standards, Spicer recommends using a search term such as, “guidelines for diagnosis, management, and treatment [insert name of condition, being as specific as possible]” Search results will usually lead you to reports or guidelines from the National Institutes of Health. You can also search UpToDateA database that compiles information about evidence-based health care practices, but requires payment of a fee.
If you’re denied because you were treated by an out-of-network provider, you may also be able to appeal, Spicer says. This No surprise act Protects consumers in a variety of circumstances, such as if you are treated by an out-of-network clinician or provider during an emergency. Erroneously listed as in-network on the insurer’s database.
Insurance companies often ask for appeals to be submitted by mail. If so, it’s “critical” to send yours via certified mail so you can track delivery, Gurewitz says. “You have to have a paper trail,” he says.
Escalate
If your appeal is denied, it’s still not the end of the road. If the company stands by its original decision, you can make a request External review In which a third party evaluates the case.
You also don’t need to stop filing appeals through official channels, says Potter. Consider alerting insurance companies, regulatory boards, local politicians or media officials to increase pressure. This works best, Potter admits, if you have a particularly sympathetic or dramatic story—if a company’s denial forced you to delay critical care or caused significant financial hardship, for example. If you don’t want to go totally nuclear, you can always call out the company on social media, Potter says.
“Being a squeaky wheel is important,” says Potter. When he worked at Cigna, he says, the company had a system for dealing with “high-profile” cases, such as those that attracted journalistic attention. “Before long,” he says, “that denial will be overturned.”
get help
If all of this seems overwhelming, call in the experts. Health advocates can help make a strong appeal, because they know the ins and outs of the system and what has worked with certain insurance companies in the past.
Consumers can work with health advocates, whose services are often free, through private companies such as ConsolationCharitable organizations like Patient Advocate Foundationor state-specific organizations such as CHA. Sometimes, employers also offer health advocacy services as an employee benefit. A soon to be launched startup claimable It also promises to use artificial intelligence to sort through medical research, information about your insurance plan and health history, and past appeals data to craft a better shot at work.
Whatever path you take, 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 paperwork.”
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