published Saturday, January 23rd, 2010

Phillips: Steps to fight claim denial by your insurer


by Ellen Phillips

Continuing last week's column concerning insurance companies' denial of claims, compliments of Agitated Agatha:

Let's say you've written for and received the specifics of a denial, but you still disagree with its findings.

Check the denial form to see the length of time in which you must file the appeal, usually anywhere from 60-180 days. If you've documented well, as I always urge, it'll be no problem to return to your original health problems, doctor visits, diagnoses/treatments, prognosis, and so forth.

Perhaps three months of physical therapy fails and you're still unable to walk without crutches, necessitating surgery. Whatever the treatment, also be sure to notate professional articles or online healthcare sites, such as www.mayoclinic.com, that provide types of treatments best for your particular trouble. Then write the appeal, documenting each and every piece of information factually and succinctly.

Be absolutely positive your facts are straight. Don't make any assertion that's even a minutia of exaggeration or falsehood. If you're caught in a lie -- even if one of omission -- forget about any help for now and for the future. In fact, you just might find yourself dropped altogether and join the ranks of the uninsured.

Definitely challenge the company's rulings about any drug not on the formulary list; after all, a generic either may not be available or appropriate for your treatment. Secondly, if a particular physician/surgeon or facility wasn't on hand and you went to another, don't take "Ira Insurance's" denial at its word.

Emergencies occur in areas not around your home radius or the base areas covered by a plan. Perhaps Ira would prefer you to collapse and die on the side of the road instead of seeking the best and most convenient treatment.

When your claim is more than a couple of hundred dollars and/or depending on your affordability, I always urge folks to send a copy of your letter to regulatory agencies. When cc'ing these agencies, include patient advocacy groups in your list of copies.

For example, the National Patient Advocacy Foundation (www.npaf.org) is a national nonprofit organization that improves access to and reimbursement for high-quality health care through regulatory and legislative reform at the state and federal levels.

Along these same lines, its sister branch, the Patient Advocate Foundation, provides professional case management services at no cost to individuals confronting healthcare access problems, medical debt crisis and job retention problems caused by a chronic, life-threatening, or debilitating conditions.

PAF's national headquarters is based in Newport News, Va., with offices in California, Iowa, Florida and New York. For information or assistance to obtain health care services or to navigate the health care system, contact Patient Advocate Foundation at 1-800-532-5274 or visit it online at http://www.patientadvocate.org. Additionally, seek assistance from your state and federal congressman.

Be certain you contact the state's commissioner of insurance whose office is there to help consumers with many, many insurance problems. Tennessee's brenda.wheeler@state.tn.us who covers general health care and accident, long term care and Medicare supplement; robert.turner@insurance.alabama.gov is in charge of that state's life, health, and annuity; and pclark@oci.ga.gov covers health and life issues. (To keep abreast of all commissioners, go online to www.naic.org.)

If you're covered under your workplace plan, use its human resources department or even the boss herself to help you. Oftentimes, the person in charge of your company's plan will advocate on your behalf. Frankly, if your employer is large enough to give lots of business to Ole' Ira, he'll usually think twice about turning down your appeal, especially as he doesn't want to tick off the officers who decide on your company's insurance benefits. Always hit 'em where it hurts -- the wallet.

And finally, if all else fails, you may wish to consider a lawsuit. Be very cautious, though; unless it's a case of personal injury and your lawyer gets a large portion of the settlement but no upfront money, a good attorney costs big bucks. Following the free consultation, unless you two are certain you'll be rewarded in court, better think about setting up a payment plan with the health care professionals to which/whom you owe money.

Ellen Phillips is a retired English teacher who has written two consumer-oriented books. Her Consumer Watch column appears on Saturdays in the Business section of the paper. An expanded version is at www.timesfreepress.com under Local Business. E-mail her at consumerwatch@timesfreepress.com.

about Ellen Phillips...

Ellen Phillips is a retired English teacher who has written two consumer-oriented books. Her Consumer Watch column appears on Saturdays in the Business section of the paper. An expanded version is at www.timesfreepress.com under Local Business.

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