How to fight your health insurer

By Bankrate.com

When a health-care claim is denied, you may feel like you've hit a dead end. Money is the last thing you want to deal with when you or someone in your family is sick, and now you've got to expend energy fighting for what you've been promised.

The reality is that denials of health-care claims, even for named benefits, happen all the time. A denial isn't the last word -- it's the beginning of the appeals process, the next stage in the game.

You are not alone, says Nancy Davenport-Ennis, the president and CEO of the Patient Advocate Foundation, a national nonprofit organization that serves as a liaison between patients and their insurers.

"The more likely your illness is to be chronic, requiring routine and regular medical care, the more likely you are to face denials," she says. "If your diagnosis is for a very difficult, expensive illness, your (chance of) denial is increased -- if you are, say, a 34-year-old woman with Stage 4 breast cancer."

Of the cases the Patient Advocate Foundation oversees, 94% were initially denied benefits that were published benefits in the health plan. "Receiving a denial of benefits is not unusual -- it is completely usual," Davenport-Ennis says. "Be confident that there is an appeals process and immediately begin it."

Facing denials

There are three to four levels of appeals. The first is a simple appeal in which you state your case in writing. In the second round, you send a more-detailed letter along with a doctor's letter explaining why your treatment is needed.

At this point, if you can't understand why your appeal was denied, call your provider and ask where in your plan it states that your particular medical care isn't covered, Davenport-Ennis advises. "Absent that, you don't know what you're fighting," she says.

Next is generally a three-party panel and after that, court.

Video: Get your insurance claims paid

You may find yourself entering the dispute process when you or your physician attempt to get pre-authorization for a health-care service or after the fact, when you receive an explanation of benefits (EOB) form from your insurer saying that your claim was denied. Whatever the case, do not accept a denial through a voice mail or a phone call. Get the denial in writing, Davenport-Ennis says.

Before making your first phone call to begin the appeals process, start a notebook to keep your appeals diary. Record the date, the name of the person you spoke with, the subject of that discussion, the purpose of the call, and any promises made and when they were expected to be fulfilled. If a representative says something will be done in three days, make a note to follow up after three days.

Continued: 3 stages in the appeals process

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