When Insurance Says No

[Guest guest]

Got this from one of my other groups, thought it might help someone.

Jeanne in WI

CONTROL OF YOUR HEALTH

Fight for Your Health Care

By Lori s

Published: January 20, 2008 Chances are, if you're among those Americans lucky

enough to have health insurance, you will eventually have a claim rejected. And

even if that decision appears arbitrary and unfair, you, like many of us, may

just roll over and accept the verdict. Fighting the health-insurance bureaucracy

on even small matters can be draining. And winning seems like such a long shot.

But that really isn't true. Surprisingly, people who fight back when their

health-care provider says " no " often do win. The keys are knowing what will get

results and being persistent.

Whether your health plan is a traditional insurer, a PPO or an HMO, and whether

it dismisses your claim or agrees to pay only part of the bill-here are the

steps to take:

1. Know Your Rights

When coverage is denied for a treatment or drug, it is up to you to collect

information and make the case for coverage. This is true whether you are seeking

pre-authorization before you receive a service or are disputing an Explanation

Of Benefits form sent to you in response to an unreimbursed claim.

First, check your rights under your health-care plan and under state law. If

your employer provides your insurance, call your human-resources department to

get a copy of the policy. Read it carefully. The policy will tell you what is

covered and what mechanism you can use to challenge your health plan's

decisions. If you don't understand the provisions, ask someone in human

resources for help or call your insurer's customer-relations number for an

explanation.

Health plans are required to follow state and federal law for handling

complaints and appeals. Find out your own health plan's internal review process,

then follow it.

2. Contact the Insurer

Get your paperwork together before you call the health-plan insurer. (You'll

find the phone number on the form that was sent to you with denial of your

request for reimbursement. It also will be on your policy.) Be prepared to lay

out all the evidence to convince your insurer that your position is correct.

Your dispute may be resolved with your first informal call, but that call also

may be the start of a lengthy process. Make a file and start keeping accurate

records of every contact you make: whom you spoke with, the date of the

conversation, what was said and when they said the next step would occur.

3. File a Written Appeal

If you don't get results from a phone call, file a written appeal with the

health plan. To prepare the appeal, request a copy of your entire claim file

from the health plan, advises C. Jaff, an attorney who is the executive

director of Advocacy for Patients With Chronic Illness. The file will include

the plan's specific rationale for rejecting your claim. Tailor your letter to

the plan's criteria for denial or acceptance and attach supporting documents.

If the claim file says the treatment was " unnecessary, " attach your medical

records. These should include test results and an explanation of why other

treatments have failed as well as a letter from your doctor about why you needed

that treatment.

If payment for your treatment is declined as " experimental, " you'll have to show

that the procedure you had is now medically accepted. You can do this by

searching on the Internet or at your public library for articles in medical

journals that demonstrate the effectiveness of the novel treatment you are

trying to get covered.

Make sure you file the appeal within the designated time limit. Some plans, for

example, require that you challenge a reimbursement denial within 60 days. The

two biggest mistakes patients make in their appeals are not providing enough

background material to justify coverage and not meeting deadlines.

4. Get Outside Help

If you have a chronic condition such as diabetes or cancer, or even a rare

condition such as Crohn's disease, the advocacy organization devoted to that

disease can help you frame your appeal. For example, the website for the

American Diabetes Association, www.diabetes.org, provides information for people

who are having trouble getting health-care coverage. Although the website is

targeted to people with diabetes, the advice is helpful for all patients.

5. Demand An Independent Review

Starting in 1990, managed-care enrollment in the U.S. increased by 85%. As more

patients signed up, more of them also began to complain to their legislatures

about denials of coverage by their health plans.

State lawmakers listened: 43 states plus the District of Columbia have enacted

some version of a Patient's Bill of Rights. As a rule, these laws give consumers

the right to an independent medical review when a health plan denies coverage

for care or access to out-of-network providers.

But few people make use of these mechanisms. In Illinois, where about 1.5

million people are enrolled in HMOs, only one in 225 members a year files a

complaint with the HMO. Far fewer-one in 2250-take the appeal to the next level

by asking for an independent review of their claim.

That's a mistake. Although success rates differ from state to state, consumers

tend to prevail in these challenges about 50% of the time.

Health-care insurers made profits in the billions last year. Know your rights,

so profits will not be taken unfairly from your own benefits.

Change The System!

Even after you've won the right to be reimbursed, other members of your health

plan could be denied reimbursement for the exact same procedure. Here's how to

help state lawmakers bring about change:

Get the insurer to do the right thing. Let your state legislators know that an

independent medical review found in your favor. If lawmakers see that a company

repeatedly denies payment for a particular procedure (but then reimburses only

those who complain loudly enough), the state could pressure the company to cover

the service for everyone.

Change the law. Some consumer groups have persuaded state legislators to pass

laws mandating certain services. As a result, at least 15 states now require

insurers to cover some infertility treatments, 20 states cover speech services,

and 46 cover diabetics' supplies.

Lori s is a health law professor at Chicago-Kent College of Law.

Take Action!

Use the Web sites below to learn about health-care rights in your state and how

to exercise them.

For step-by-step guidance to challenging health plan decisions:

http://www.kff.org/consumerguide/upload/7350ConsumerGuidev4_080805.pdf

For information on what special mandates your state has for health insurers, see

the report of the Council on Affordable Health Insurance:

http://www.cahi.org/cahi_contents/resources/pdf/MandatesInTheStates2007.pdf

To learn whether your state has a law providing an independent review of denied

benefits, see the charts created by the National Conference of State

Legislatures, http://www.ncsl.org/programs/health/hmolaws.htm

To learn what new laws your state is considering about health care, see the

National Patient Advocate Foundation website,

http://www.npaf.org/state/state-by-state.html