The Claim Game

It happens 500,000 times a day: and insurance company denies a health claim. Here’s how to fight back when your insurer says no.

TO MAKE INSURERS PAY

When your claim is denied…

1. Don’t pay the bill.

2. Get a reason for the denial in writing.

3. Review and follow your plan’s rules.

…Make the easy fixes…

· Missing information? Fill it in.

· Coding mistake? Have your doctor fix it.

…And assess other reasons for the denial.

· Preexisting condition

· Lifetime-benefit cap

· Change of employer, so coverage was delayed

· No network facility or physician was available

· Drug wasn’t FDA-approved for your illness

· Treatment was deemed unnecessary or unproven

When preparing an appeal…

1. Check the back of your denial notice to see how long you have to file – it’s usually 180 days.

2. Gather objective evidence of medical necessity, such as test results and prior failed treatments.

3. Gather journal articles showing the treatment is safe, effective.

4. File the request in writing (certified mail, return receipt).

If you want help, seek out…

· A nonprofit patient advocate (your state’s insurance regulator or a disease association can suggest names).

· A lawyer if there’s a large sum of money at stake and you might end up in court.

Source: Caroline E. Mayer