Have a hard time getting your insurance company to pay for your medical bills? Come join us. When managed care came to insurance a decade ago, its goal was to keep medical costs from going up too much. One way to do this is to reject claims, even if they are true. Because of the backlash from customers, many states set up independent review panels and made insurance companies make their own internal appeals processes. Independent review boards have been set up in 42 states, and their decisions can be used instead of those made by insurance companies. Most people don't even know that there are review boards.
Another problem is that too many people give up when their first insurance claim is denied. The appeals process can be long and frustrating, and many people don't have the patience or time to pursue a claim, no matter how valid it is. People can win if they don't give up. Especially if there's a lot of money at stake, the time you spend trying to change an insurance company's decision can often pay off faster than you think. A recent study by the Kaiser Family Foundation found that for every claim made, 52 percent of patients won their first appeal. The insurance companies are no longer getting things for free.
If your first request is denied, keep trying. The study found that 44 percent of the time, people who appealed a second time were successful. People who went to court a third time and won 45 percent of the time. So the odds are always in your favor, no matter how long it takes. Remember that every time you appeal, it costs the insurance company more money to fight you, and they will lose money both to you and in court costs. Medical health benefits are tricky because insurance companies usually have a limit on how much they will spend or how many visits they will pay for in a given year. But there is usually some wiggle room if you can prove that your health or the health of your child requires more care than your policy usually covers. Here's what to do first:
Get your work done.
Look over your Policy: What's in it for me? What kind of services comes with it? Outpatient or inpatient care? Is the diagnosis "serious" or "not serious"?
Learn the rules: Contact your state's Health Association to find out what the law says about insurance payments for all illnesses in your state. Is full or partial parity required in your state? Are parity benefits only for people with "serious illness," or do they also cover people with "non-serious illness"?
Document everything in writing: Some insurance companies may not consider some diagnoses serious. In this case, you will need proof of services to prove that you need them. Get a letter of medical necessity from your doctor and test results that show why you or your child needs certain services based on the diagnosis.
Record things well: Don't forget that you'll have to deal with bureaucracy. Keep track of the names and phone numbers of everyone you talk to, as well as the dates and what you talked about.
Start early. If you can, start the process of appealing before you start treatment. If the doctor says your child needs to see him or her once a week for a year, you should start right away to change your insurance company's policy of only paying for 20 visits a year.
Call the company and ask them:
What do you need to do in order to get health benefits?
How many times can you or your child see the doctor each year? Can more than one service be done on the same day and still only count as one day or one visit?
Who needs to pre-certify which services and how?
Be happy, kind, and patient with the person who is helping you. Remember that he or she is just a messenger and not the one making the decision. They are the gatekeepers. Depending on how you deal with them, they can either let you talk to a decision-maker or make your life miserable.
Be persistent. There's no silver bullet. Don't give up until you get the answer you want. Be like a dog with a bone. If you call several times and get nowhere, ask to speak to a manager or a nurse in the pre-certification department.
Remember that if your claim is turned down, you do have the right to appeal. Most people give up and don't keep trying to get a claim that should or could be paid. Insurance companies expect this to happen, so go out and get what's rightfully yours.
