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If you appeal a health insurance denial correctly and promptly, you have a chance of getting the equipment or procedure covered. Many times, health insurance companies automatically deny anything that isn’t routine. It’s up to the patient (or the patient’s parent) to be persistent and get coverage by appealing the denial.
I recognize that the time and mental energy needed to fight a huge corporation may beyond your abilities, especially during times of stress. I’ve been there, which is why I created this guide to help make the process a bit easier.
I recently interviewed Mary Thompson, an amazing occupational therapist with 26 years of experience. She now works for a rehabilitation provider, appealing health insurance denials for their clients. Over the last 4 years, she’s learned a lot about appeals and dealing with insurance.
Quick Tips for Appealing Health Insurance Denials
Keep a log of everyone you talk to when you contact your health insurance provider.
- Representative’s name
- Representative’s title
- Date & time of the phone call
- What was discussed
If you have the representative’s email address, send a quick email after the phone call. Summarize what was discussed and lay out your interpretation of the next steps or what is needed. This will help reduce the chances of miscommunication and cover you if there is a disagreement about the call later.
Pay attention to deadlines
There are deadlines throughout the appeal process. If you’re trying to get coverage for an expensive item or treatment, missing a deadline by a single day is enough for the insurance company to continue denying coverage.
Usually, you have 30-60 days from the date of the denial to submit your appeal. The exact appeal process varies by the health insurance provider. It’s important to figure out the specific steps you need to take and when to take them.
If other steps are required, such as a second appeal, there will be additional deadlines to watch for. Always create a reminder for the appeal deadlines.
Develop a filing system for insurance-related documents so you can find exactly what you need when you need it. You should keep an exact copy of every letter you send to your insurance company.
When someone in your family is medically complex, I highly recommend investing in a scanner and storing the documents electronically. Use cloud storage, like Google Drive or Dropbox, as a backup in case your hard drive crashes.
Whether your files are paper or electronic, keep them organized in a way that makes sense to you. My electronic files are categorized by topic (appeals, receipts, travel, education, etc.), then by year. I also use the search feature of File Explorer to find what I need.
I create file names that are as descriptive as possible and include the date or month.
When physically mailing letters to your insurance company, always request a tracking number for the envelope. You may need to later prove it was mailed before the deadline, and it’s nice to know when/if it is delivered. We have no control over the postal system, so proving you mailed the document before the deadline covers your bases.
When faxing your insurance company, you can use a free service like FaxZero. You upload a PDF file to the website and confirm via email. The service will send an email when the fax has been successfully sent.
Do your research
To effectively fight a denial, you must know what your health insurance policy will and will not pay for. Ask for specifics of the denial, but also request the policy related to the requested coverage.
It may also be helpful to find out if Medicaid covers the specific service or equipment you are trying to get. Even if your health insurance provider doesn’t follow all the Medicaid rules, you have some justification in your appeal if the US government covers that thing.
Remember, health insurance is a business
Health insurance companies are businesses and their purpose is to make money. They’re not really trying to help people. Don’t expect a lot of sympathy or altruism.
Of course, great people are working for these companies, but the overall goal of an insurance company is to turn a profit. This leads to a lot of denials on the first attempt. The less they have to cover, the more money they make.
Basic Process for Appealing a Health Insurance Denial
1. Request coverage for a service or equipment
Your provider (doctor, therapist, etc.) will submit the required paperwork to get a preauthorization before the service or to bill insurance after.
TIP: when you receive a bill from a healthcare provider, make sure the charges are appropriate and legitimate. You can request an itemized statement so you can review every single charge.
2. Receive a denial letter and/or Explanation of Benefits (EOB)
Both the patient (you) and the provider will receive a notification when something is denied. The reason given will probably be vague.
Mary Thompson said some of the more common justifications are “lack of medical necessity,” “experimental treatment,” or an error. If you’re lucky, it’s just a clerical error, which can be fixed easily. I’ll explain these terms and how to appeal these specific denials later.
3. Call your insurance company
Ask your health insurance company why the denial was issued. They’re required to give more detail, but you have to ask for it.
Put “work on appeal” on your calendar to make sure you get around to it AND have enough time before the due date.
Inquire whether your health insurance company provides a healthcare advocate, medical social worker, or nurse advocate for their subscribers. This person should be able to help you understand your benefits and why the claim was denied. They may also be able to help with the appeal process. Not every insurance company provides this benefit, unfortunately.
4. If the denial is due to a “lack of medical necessity,” get more information
Ask the health insurance company representative to email you the company policy related to the service or equipment you want to be covered. Getting the correct policy from the company will save you a lot of time, so you don’t have to try to find it on your own.
You’ll use this information to craft your appeal letter. Quote the policy back to the company to show how it applies to the patient you’re advocating for.
5. If the denial is due to a clerical error, contact your provider
The easiest error for the patient to get resolved is a clerical error. When the wrong billing code is used, or something similar occurs, simply call your provider’s office and ask them to resubmit the claim. Once the corrected claim is submitted to the insurance company, it should be approved.
Your provider’s office can, and should, handle the resubmission and any associated insurance company correspondence without further involvement from you. You should keep an eye on your EOBs and the bills from the provider’s office, still.
6. Follow the appeal process
If you’re going to go forward with an appeal, make sure to ask for details of the process. The denial letter will detail the appeal process but clarify the steps with the representative while you have them on the phone.
Make sure to follow the process exactly as detailed, and stick to the deadlines.
7. Always ask what the next step is
An appeal is not guaranteed to be successful. Ask what the next step is if this appeal is denied. This lets the insurance company know that you’re not going away and will pursue the matter.
8. Follow the process, but don’t be afraid to go beyond
When a first appeal is denied, you often have the option to appeal again, and then you may be able to request a medical review. Keep pursuing coverage, especially if it’s a crucial service or piece of equipment.
Another option is to request an external review. This moves the appeal outside the health insurance company, where a third party makes a decision on the claim.
In the most extreme cases, you can always mention your willingness to take the matter to the state insurance commission. If you do go that route, exact copies of the letters you’ve submitted to your insurance company already will bolster your case.
Why are health insurance claims denied?
In the best-case scenario, a claim is denied due to a clerical error, either at the provider’s office or at the insurance company. Examples of errors include: the wrong billing code is used, a date is incorrect, or something else is just entered incorrectly.
Once you find out the case of the denial, you can ask the provider’s office to correct the error and resubmit the claim. Usually, that will solve the problem and the claim will be processed.
“Lack of medical necessity”
This phrase is kind of a catch-all euphemism for “we don’t want to spend the money, so we’re testing how serious you are about this” (that’s my interpretation from my own experiences).
Mary did say this was the primary reason she sees for denying a claim. Since it’s a vague reason, it can be hard to know where to start appealing, especially for a layperson. This is when you ask for specific information about the denial, including a copy of the insurance policy that applies.
You then need to relate the policy to the patient – show they meet the conditions outlined or demonstrate the need for the treatment concerning the policy. Quote the policy in your appeal letter to show you’ve done your research and it applies to the patient.
The patient may also need to follow the steps outlined in the benefits policy. Often, you have to try and fail other treatments first, before something more expensive will be covered. For example, when getting approval for my daughter to start a new epilepsy medication, we had to show she’d unsuccessfully tried several other medications first. The process should be outlined in the policy.
You may be able to avoid some of the steps in the appeal process if your provider’s office appeals on your behalf. They’re not required to and are often too busy to do so, but an appeal from a medical professional can go a long way. A professional explaining why the other treatments won’t work can save a lot of time and wasted effort.
When you’re told the denial is due to the treatment being considered experimental, ask for more information. “Experimental” is defined by each insurance company, so you need to know why.
A treatment not recognized by the FDA could be experimental, even if it’s the best course of action in other countries. Your health insurance company could also decide there isn’t “enough” evidence to support using the treatment.
The provider’s office is a good resource when appealing an “experimental” denial. Ask for help finding research published in accredited medical journals to bolster your appeal.
Out of network
Each health insurance company has its own network of providers. The doctor you see isn’t guaranteed to be in-network, so it’s important to check coverage before even making the appointment. It’s much better to find out before the treatment. That will allow you to appeal the denied reauthorization rather than appealing the health insurance denial.
You’ll likely have to pay for out-of-network treatments if appealing after the fact. If you’re lucky your policy’s out-of-network plan will pay a portion of the bill, but it may not pay anything. Some plans will even cover out-of-network providers the same as in-network, especially in rural areas.
Health insurance is more likely to cover emergency expenses. Unexpected, time-sensitive treatments can’t always be performed by an in-network provider. That’s a good basis for an appeal.
Writing your appeal for a health insurance denial
Identify the patient
In addition to including the date of the appeal letter, make sure to list:
- The patient’s first & last name
- Patient’s address
- The name of the person appealing (if you’re not the patient)
- Insurance ID number
- Patient’s date of birth
- Provider name
- Date of service (if it has already occurred)
The treatment/equipment is “reasonable and necessary” to “improve, prevent, or stabilize the condition.”
Know that the treatment doesn’t necessarily have to improve the situation to be reasonable and necessary. Preventing a decline or complication, or stabilizing a current condition that isn’t going to change, is enough.
The Jimmo settlement ruled that improvement isn’t a necessary condition of a “reasonable and necessary” treatment. I recommend researching how this ruling applies to your specific situation, then using that knowledge in your appeal letter.
The treatment will “facilitate the approach or approximation of a milestone or building block.”
For pediatric patients, point out that the child needs the treatment to make gains toward age-appropriate milestones. Even if the child never actually reaches that goal, improvement is important.
The treatment “facilitates communication of wants and needs” of the patient.
When you can’t communicate your wants and needs, there’s a high chance they won’t be met. Any treatment that assists in this process should be justifiable.
The treatment “improves the patient’s ability to get their basic human needs met.”
Anything that affects a person’s ability to care for themselves or impacts another person’s ability to care for the patient is reasonable. Denying these treatments can drift into areas of neglect and abuse in the worst-case scenarios.
Show who the patient is
Go out of your way to humanize the patient as much as possible. Use their first name, mention how the denied service or equipment is/could improve their life, and include photos of cute young patients. You want the people at the insurance company to see you & your family as real people, not just a claim.
If you can, send a short video. It’s powerful to actually see the real person involved.
Involve the provider
I always like to get a letter of medical necessity from the provider. That letter will have more medical information and carry more weight with the insurance company. Make sure to include the letter with your appeal letter.
A really great provider with a fully-staffed office may even file the appeal on your behalf.
Appealing Health Insurance Denials Before the Service
When you’re planning an expensive procedure or medical purchase, it’s always a good idea to have the provider’s office ask your health insurance provider if a preauthorization is required. This is an approval process that occurs before conducting the service or ordering the equipment.
If the preauthorization is denied, you can appeal using the strategies outlined here. An appeal is more effective if it comes from the provider’s office, but there isn’t always time for that. I know from personal experience that patient appeals can also be approved.
As much as you can, anticipate what treatment, therapy, surgery, or equipment you (or your child) will need ahead of time. It takes forever to get expensive things approved, ordered, scheduled, and implemented. It’s less stressful to start the process early before it becomes critical (like when your kid outgrows their wheelchair but has to squeeze into the old one for months while waiting on the new one).
Your tenacity is probably the most important factor in whether a claim is approved. Giving up guarantees failure.
Mary stated, “so many people just can’t.” They can’t continue fighting, they can’t invest the time required, or they can’t overcome their depression or anxiety. Unfortunately, successful appeals of health insurance denials often depend on being able to do these things.
I wish I could refer you to a resource that walks you through the appeal process and really holds your hand, but I don’t know of such an organization. The Patient Advocate Foundation looks promising, so check it out if you need more assistance.
In my own life, I have filed multiple successful appeals on my daughter’s behalf. I’ve written second appeal letters and requested a medical review. I know how hard all of this is, how much mental energy it takes. Just remember that you can do this, especially when it’s really important.