Insurance Appeals

In a previous post I talked about how to get an in-network exception from your insurance company – this is one way of appealing to get the services you need from he providers you see.  But it must be done up front.

Here’s what I said:

If a patient has insurance but cannot find a provider on their plan that is accepting patients or treats their specific illness, there is the ability to ask the insurance company for a special exception (or in-network exception – this may have a different term depending on the insurance provider).  Insurance plans must include enough providers in their network to cover their insureds.  For instance, a plan must have a hospital in the network, oncologists, radiologists, etc. and they must contract with enough of them for all the people on the plan (this is called network adequacy).  If they do not have enough or a certain provider, they have to allow the insured to see a provider outside their network and pay reasonable billed charges (not just the charges they are willing to pay). Simply ask “I would like to request an in-network exception based on the fact that there are no contracted providers where I live who treat or are willing to accept patients with [mental illness]”

But what happens if you get a huge bill for a provider (doctor, hospital, etc.) that you’ve already seen? Then you need to appeal to get retroactive approval. Reasons you might be able to appeal are many.  For instance, if the paperwork contained the wrong code for the services you received or the code relates to a service that wasn’t “medically necessary” or deemed “experimental.” These codes are super specific and easily mixed up, and they are being revised soon (with the coming of the ICD-10).  You could also see a doctor in a hospital but find out the doctor wasn’t in your network.

Appeals are often successful and the Affordable Care Act should help with your ability to appeal.  Under it, your insurer must inform you that you can appeal claims through the insurer’s appeal process or through an independent review organization.  And if the insurer denies a claim, you can go to an external independent review organization.  Unfortunately the rules for patient appeals are narrower than they should be.  Patients can appeal if their insurer declines to pay for care on the basis of medical judgment, but not when the dispute is based on coding or whether a patient should see a medical specialist outside their network.  And instead of 4 months to file a complaint, patients have only 2 months.  While the rules may not be ideal, this law which will inform consumers about their right to appeal is a big step forward.

As estimated by the feds – about 31 million people in new employer plans and 10 million people in new individual plans will benefit from the these appeal rights next year.

The thing is, you have to be your own advocate.  It’s unfair when you’re maybe feeling unwell and your resources are low, but you have to take the steps to ask for help either by asking a patient advocate in a hospital, calling your insurance company to have them explain in detail the charges you they didn’t cover, filing for appeals, asking for in-network exceptions.  Don’t give up.  Don’t quit.  It’s no easy process, but it’s worth it if you get the health care you need and don’t go bankrupt in the process.


See also this Washington Post article

Another great help to learn about insurance appeals and other assistance is the Patient Advocate Foundation who work to provide effective mediation and arbitration services to patients to remove obstacles to healthcare including medical debt crisis, insurance access issues and employment issues.


2 Responses to Insurance Appeals

  1. jennifer says:

    I appreciate the tips. I spoke with one of those patient advocates once and they are a little sketchy. Are they on my side or the hospital’s? They work for the hospital so it’s weird that they consider themselves on my side. But at least it’s someone to talk to and get info from. Thanks for the ideas on working with these bastard insurance companies.

  2. […] Trent Hamm, author of The Simple Dollar: Financial Talk for the Rest of Us blogged about Tactics for Appealing Health Care Denials.  I encourage you to read this post as it gives great step by step instructions to help you in your insurance appeals which I talked about in a previous post. […]

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