Consumer Watch: How to appeal medical claims

Consumer Watch: How to appeal medical claims

February 9th, 2014 by Ellen Phillips in Business Diary

Ellen Phillips

Ellen Phillips

I've just received an almost $1,000 bill from a health provider that, between Medicare and my secondary insurance plan, should have been covered. I can't seem to get anyone explain why my claim was denied. Can you help?

- Paul Patient

Dear Mr. Patient: According to Bottom Line Health, over 200 million claims are denied each year. Sometimes the problem lies with doctors' and hospitals' failure to complete claims and/or errors made by the insurance companies themselves. But these days more and more are denied because the companies (or Medicare) believe the treatment isn't necessary or is considered to be experimental. Either way, you're the big loser. So what can you do to reverse their decision?

• Read your policy. I feel confident enough to bet $5 million - if I had it - that most folks never read their policies to see what's covered. (In fact, if I didn't need to be on the top couple of rungs of the consumer advice ladder, our family's policies likely would go straight from the mail carrier into the fireproof box my husband and I maintain for such purposes.) With that said, you obviously can't do a whole lot to rectify the issue if your policy spells out what it will or won't cover. However, don't stop there. Because insurance companies are notorious for altering coverage at any time it wishes, be sure to call and get pre-approval for any invasive or extensive/new procedure. As always, get the full name of the person with whom you speak and any other helpful, identifying information, such as the agent's location and contract number.

• Be the upfront guy or gal. Don't depend upon the medical provider to fix the problem for you; call the insurance company yourself. And as I always urge, keep a record of any type of "transaction;" in this instance, calls and correspondence with docs, hospitals, labs, and any other insurer that's related to the denied claim becomes the backbone of a future appeal, whether it's to Medicare or to a private insurance company.

• Don't dawdle. It's the law that all insurance companies offer an appeal process. If you don't already have access to these guidelines, get them quickly. Call the company to ask about its "insurance appeal procedure" and to whom you should submit the paperwork. Unfortunately, they don't advertise that time limits can be as few as 60 days. And a couple of months pass oh, so quickly, because recuperating from surgery is truly about the only thing that fills our days. To ease the transition, have the hospital social worker or the physician him or herself step onto the battlefield. In fact, have each submit a "letter of medical necessity" to explain in great detail why the denial should be overturned. If you are under a Medicare plan, be assured it has an extensive appeal process. Check out "Claims and Appeals" on the website or call (800) 633-4227.

• Keep fighting. And don't forget that flag we carry onto the battlefield is never, ever white! Even if the appeal is further denied, don't stop here. Go to your state's department of insurance commissioner where an outside, hopefully impartial panel of experts will review your case. In this step - and depending upon what you're appealing - be sure to include any and all pertinent research you've gathered. Medical journal articles, opinions from a third party, such as a pharmacist, and any other support can "prove" the care you received was a medical necessity. Keep these numbers handy for area Departments of Insurance Commissioners: Alabama - Jim Riding (334) 269-3550; Georgia - Ralph T. Hudgens (404) 656-2070; and Tennessee - Julie Mix McPeak (615) 741-2241.

Ellen Phillips is a retired English teacher who has written two consumer books. Email her at