If your health insurer denies a claim, you have the right to appeal the insurers’ rejection. From 2000 to 2006, the number of consumers appealing claims increased by 34%. Here are some strategies you can follow if you need to appeal a denied claim:
Write a good letter. Consumers (patients) who write insurers to appeal a claim are more likely to succeed if they include in their letter references to medical research. Some advocacy groups and associations offer helpful letter templates for common denials. You can look up these organizations in Google. Be sure to include every detail in your letter like dates, who you talked to, titles and contact information.
Get a second opinion. Obtaining an extra, concurring opinion adds credibility to your argument. Prestige also matters. Recruiting top doctors in the field can help your appeal.
Stay calm and collected. When the appeals process reaches a second round, the consumer will often get to talk on the phone or meet in person with a medical director from the insurance company. These conferences are as little as 10-15 minutes long. Staying calm and avoiding yelling and screaming will waste your time in this meeting/conference call.
Look for loop-holes. Many employers have outdated or poorly written summary plan documents, also known as your contract with insurers. These outdated documents can sometimes help “open doors” in the appeals process. Copies of the contracts should be available in an employer’s benefits office. If you have individual health insurance, make sure you keep a copy of this contract when you sign up for the health plan.
Private health insurers reject tens of millions of medical claims every year, leaving patients scrambling for alternatives. The October issue of SmartMoney includes an interesting article, Paging Doctor No that shadows an insurance-company medical director to see how the toughest decisions get made.