published Sunday, October 6th, 2013

Consumer Watch: How to make sure insurance pays for hospital procedures

by Ellen Phillips

Q: I’m having a terrible time getting my insurance company to approve an in-patient procedure. Any ideas to help them along? — Paul Patient

Dear Mr. Patient: You don’t state whether your procedure is mandated or cosmetic. If the latter, you’ll probably have to eat the hospital and other related costs. On the other hand, assuming this is need-based surgery and, for whatever reason, your insurance is declining the coverage, then you probably have recourse. Bottom Line and I suggest the following:

• Enlist your doctor’s help. Often, providers list the wrong procedure code in the paperwork or don’t always give enough detail to justify payment. First, you give it a try. Call the company’s customer service number and request the exact reason the claim was declined. Then call your doc’s office and turn it over to whoever handles billing. Many disputes are often resolved when this person resubmits the claim with the pertinent documentation that the insurance company needs.

• Involve your employer. If your insurance is provided by your employer, contact the benefits manager and ask that he or she contact the insurance company to plead your case. Believe me — the insurer doesn’t want to lose this business.

• Appeal the decision. Medicare and all states have an appeal process for denied claims. If a private insurer, call the customer service number and ask for a claims appeal form. While the claim is under appeal, you usually don’t have to make any payment. For those of us on Medicare, call 800-633-4227 and have a form sent or download the form at

n Grab onto regulatory agencies. In this case, your state insurance department/commissioner is your very best friend, especially if your appeal is denied. (Personally, I would contact the commissioner for help during the appeal and not wait until the proverbial fat lady has sung.) This state agency will review the insurer’s decision to determine whether it’s correct under the terms of your policy and state law. For an updated list of commissioners, check the National Association of Insurance Commissioners at or call 866-470-6242.

• Hire a lawyer. After you’ve explored all other avenues, find area attorneys who are good at what they do. Call the local bar association or consult, a free service sponsored by LexisNexis. And, of course, always ask for referrals from friends and colleagues.

Ellen Phillips is a retired English teacher who has written two consumer-oriented books. She may be reached at

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 under Local Business.

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