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When you buy a health insurance plan, you expect it to be there for you when you need it most. In exchange for your monthly premiums and a certain deductible and co-insurance percentage, you are purchasing financial security in the event of a severe health issue. Treatments for major conditions like cancer can cost millions of dollars. In an attempt to maximize their revenues, health insurance companies seek to pay out as little in claims as possible. While detecting health insurance fraud is a laudable goal (and catching medical fraud helps everyone save on individual health insurance premiums), innocent people get caught in the crossfire.
There are several reasons why your health insurance claim may be denied:
The procedure, treatment, or medication is specifically excluded from your health insurance policy.
The health insurer considers the procedure to be an experimental treatment; as a result, they refuse to pay for an unproven treatment.
You visit an out-of-network hospital emergency room or clinic.
There is a clerical error; for example, an incorrect address or diagnostic code.
Far too many people are unaware of their options after a claim denial. Instead, they give up--a decision which costs them tens of thousands of dollars. Health insurance companies, including major providers like United Healthcare, have appeal procedures. Sometimes it will take multiple appeals for you to get your claim covered by your health insurance. Persistence is well worth it! Follow these tips to increase the likelihood of your appeal succeeding:
Make sure to file an appeal before the deadline (usually 30 to 90 days), but don't rush. Build your case and inquire for information without revealing your intentions; some health insurance companies will take that statement as an appeal in itself, making it far less likely that their decision will be reversed.
Do your homework. If a procedure is considered experimental, find research in reputable medical journals that prove it is safe or effective. It will also help your case if you are able to find proof that other local health insurance companies cover a treatment, or that your insurer covered the same treatment for other patients in the past
Get written documentation from your doctors and medical offices. Your claim is more likely to be approved upon appeal if medical professionals agree that a particular treatment is medically necessary or acknowledge that a billing or coding error occurred. If you filed an out-of-network emergency claim, those doctors (along with your medical records) can prove that there was no in-network treatment provider available.
Keep track of all discussions with your health insurance provider: date, time, and the person you spoke with. Find out exactly who can help with your appeal, and send it to that person directly. This will make the claim process move faster.
If you have a chronic illness, the health insurance claims process can be extremely complex. Advocacy associations--both general and disease-specific--can answer your questions and help you file. Failing that, it may be worth it to hire a medical billing advocate. They specialize in navigating through health insurance bureaucracies, and their hourly or percentage fee may be worth the additional peace of mind.
Contact your state's insurance department if you have individual health insurance or health insurance through a small- or medium-sized employer (meaning that you are covered directly through a health insurance company). Forty-five states have independent external review boards, which will review your claim if all or your internal appeals have been exhausted.
You may have less recourse if you receive health insurance through a large corporation that self-insures. Since the firm pays medical claims itself, it is not subject to state insurance laws. However, check your plan summary for any external appeal reviews: the majority of companies have them.
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