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Consumer Watch: How to check and appeal claims on your health insurance coverage

FILE - In this Oct. 6, 2015, file photo, the HealthCare.gov website, where people can buy health insurance, is displayed on a laptop screen in Washington. President Barack Obama told insurers his health care overhaul has some growing pains. But with premiums rising and marquee insurers bailing ahead of the fourth sign-up season, could the real diagnosis be “failure to thrive?” (AP Photo/Andrew Harnik, File)
FILE - In this Oct. 6, 2015, file photo, the HealthCare.gov website, where people can buy health insurance, is displayed on a laptop screen in Washington. President Barack Obama told insurers his health care overhaul has some growing pains. But with premiums rising and marquee insurers bailing ahead of the fourth sign-up season, could the real diagnosis be “failure to thrive?” (AP Photo/Andrew Harnik, File)

By Ellen Phillips 5 min read

photo Ellen Phillips

I had surgery about six months ago, but my insurance company didn’t pay what I thought they should. I’m out several thousand dollars that I can’t afford so I need to file an appeal. I know you’ve advised how to be sure the patient isn’t charged more than accurately but I can’t find where you talked about filing an appeal. Help, please. – David Denied

Dear Mr. Denied: I’m very proud you’re taking this particular bull by the horns and not allowing Big Business to pick your pocket without a fight. Last month’s column about rising 2017 health care insurance premiums is scary enough without Ira and Iris Insurance taking more than what they see as their “fair” share.

So what should you do to retain what’s yours? For Obamacare naysayers, appeals are much more successful now than they used to be.

(I recall a specific case back in the 1990s before I shut down Ellen’s Poison Pen. My client delivered premature twins with an extremely difficult delivery; the hospital bill ran into the hundreds of thousands but the insurance company zipped up its wallet way too early leaving Mom and Dad responsible for over $100,000. She attempted numerous times to contact the hospital administrator, as well as her advocate within the insurance company. While these authority figures sounded sympathetic, the poor – literally and figuratively – new parents continued to receive dunning notices that almost turned into a legal battle. Long story short, when I finally got involved, I did as I always advise readers and audiences to do: write that professional letter of complaint to the Head Honcho, utilizing all the methods I’ve preached, and copy all applicable regulatory agencies. Six months later (Never Give Up), not only did Mom and Dad walk away owing the hospital nothing, but all “their” correspondence resulted in the hospital and insurance provider finding several hundred dollars they actually owed the parents! Note: All of my clients over the years signed the letters I ghost-wrote for them so whatever compensation Big Business offered went into the consumers’ pockets.)

Obamacare or the Affordable Care Act requires that any time a medical provider denies an insurance claim or payment, it must do so in writing and spell out the exact appeals process. Moreover, the ACA mandates that, even if you lose your appeal, you can still appeal that one to a non-insurance third-party entity, such as the state insurance commission. Currently, up to 60 percent of appeals are won. While this number is fantastic, it’s no guarantee any of us will be in the lucky percentage so we need to increase our odds of winning.