“No one should have to be fighting and insurance at the same time,” said Arete Tsoukalas, a 26-year-old who was diagnosed with leukemia. Tsoukalas’ treatment came at a hefty price, as she was forced to shell out a $13,000 per month copay for the treatment drug she required, a copay she simply could not afford as a college student. Isaac Rosenbloom, 43, doesn’t even know if he has cancer because his insurance company won’t approve an MRI for the “nodules on his lungs.” Melanie Duquette, 70, underwent an intense back surgery, after which she was sent to recover at a rehab center, at the behest of her doctor. However, after six weeks of coverage, her insurance company has denied her to stay any longer, even though “her medical team argued she should remain.” Duquette, speaking out against her insurer, said, “[t]hey deny people care while they’re making millions of dollars.”
Sadly, the denials that Tsoukalas, Rosenbloom, and Duquette have faced are just the tip of the insurance denial iceberg – with over 850 million insurance claims denied per year. According to appeals company, Claimable, and data from the health-policy nonprofit, Kaiser Family Foundation, over five billion payment claims are processed annually. Although almost twenty percent of claims are denied, “less than 1% of patients appeal.”
While there are law firms that specialize in insurance claim denials and understand the detailed appeals process for various insurers, attempting to appeal your claim denial as a customer – especially without the information, expertise, and resources these firms possess – can be a daunting task.
Why is it so daunting you may ask. Cheryl Clark, a veteran health care reporter sought to answer this question. In her quest to create a guide for appealing insurance claim denials, she was met with the same response from insurance experts, lawyers, and physicians: “[g]reat idea. But almost impossible to do.” Clark noted that this project was essentially impossible because:
There are many kinds of insurance in the U.S., and they have different processes for appealing a denial. And no lawmakers or regulators in state and federal governments have forced all insurers to follow one simple standard.
Although the appeals process can be daunting, especially for individuals facing challenges such as battling cancer or being denied rehabilitative care (all while fighting the insurance company), the “few who appeal often win.” According to a report by the Wall Street Journal, the appeals process labors can prove worthwhile, with “up to three-quarters of claim appeals [being] granted.”
While a one-size-fits-all guide to insurance denials is likely impossible to produce, some steps can be taken to appeal a denied health insurance claim. The Wall Street Journal suggests the following five steps:
- Read up
- Understand your coverage and benefits.
- Take note
- Log dates of calls to your insurer, who you spoke with, billing codes for denied services, etc.
- Fight back
- Call your insurance company and ask why your service was denied.
- Ask how to appeal.
- Get help
- Nonprofits such as the Patient Advocate Foundation and the Medicare Rights Center may help craft appeals on your behalf.
- Escalate
- Write a letter explaining why your denied claim was not warranted. Have your doctor write to the insurance company explaining that the treatment prescribed was medically necessary. Appeal to a higher authority within the insurance company.
By reading this article, you likely know more about insurance claim appeals than your counterparts. Although less than 1% of insurance patients appeal denied claims, over three-quarters of these appeals are approved. If the insurance company is not willing to fight for your health, you must fight for yourself.