[[Home|home]]

How To Fight Insurance Denials

And why it is worth it!

Health insurance companies have no justification to exist. The fact that all the nations which do not provide their citizens' health care through such companies all, all have higher life expectancy, lower infant mortality rates, lower rates of death among women during/just after delivery strongly suggests that health insurance companies are evil. Health insurance companies kill women and babies and shorten everyone's lives. Seems like a pretty good example of evil to me.

So what can you, should you, do if you find yourself caught in the clutches of one of these vampiric bloodsuckers? As always, a good defense starts with a good offense. Prepare in advance before you find yourself in a jam.

Advance Preparations

First, start listening to the Arm-And-A-Leg podcast. Go back and listen from the beginning if you can. Take notes, many links and resources are discussed and lots of advice and examples given. Subscribe to their newsletter. Send them a few bucks, they are totally worth it.

Next, Vote! For God's sake vote in your own interest. Vote for candidates who will at least try to rein in these parasites. If you are not sure, Find out who the health insurance companies donate their money to and vote for anyone else, you're voting for your life! Start with Goods Unite Us to find out where big corporations send their political donations and vote accordingly.

What To Do When You Receive a Denial Of Care

Stay Calm

When you appeal, remember that the insurance company employees you talk with are not the enemy, they are small cogs in a very big machine. Take a deep breath, put on some quiet, calming music, and then start writing your emails and letters or making your phone calls. Always remain Politely Persistent. Be courteous, but never give up.

Stay Organized

Keep every piece of paper you receive or send regarding the claim.
Take notes during every phone call or other interaction.
Get the names of everyone you talk to.
Include the date and time of every call or interaction. (Might be useful to jot down the date you received each piece of mail as well.)
Note what you ask/say, note their response.
If they promise to call back or send something, ask when you can expect it and tell them you will be following up with a call within a few days of that date if you don't hear from them.
Note how long the on-hold was before talking to each person. Was the call cut off?
You may be tempted to record calls; seems fair to me, they do, but be sure you understand the laws on such recordings in your state before you do it. (Talk to a lawyer, I am not one).

Stay Persistent

It may surprise you to know that very few people appeal an insurance denial, no more than 10% for Medicare Advantage. At the same time, when people do appeal a denial , the denial is reversed around 50% of the time in general, and over 80% for Medicare Advantage authorizations.

It is very well worth your time to appeal!

Use The Resources at Arm-And-A-Leg Podcast

{{fighting_insurance_denials|raw}}

You Have a Right to Know Why a Health Insurer Denied Your Claim

{{right_to_know|raw}}

Additional Suggestions

Here are some additional ideas I have accumulated from various places around the web. Some may work better than others. The info from Arm-And-A-Leg is still likely the best available.

Question the Reviewer's Qualifications

The following suggestions basically attack the qualifications of the provider (physician) working for the insurance company. I have no idea how effective these are likely to be, but if nothing else works, give it try.

Ask the insurance company for the name, board specialty, and license number of the physician making the determination that your treatment was not medically indicated.
Ask for copies of all of the materials they relied on in making the determination.
Ask for documentation that the physician is licensed in your state and documentation they have met all of their continuing education (CE) requirements.
Ask for the aggregate rate at which similar treatments are denied vs approved by the specific physician making the determination.

They may not be legally required to turn over all of these depending on what state you are in but you can ask. You are likely to have a right to at least some of them even in the reddest state. Some folks claim that health insurance companies are often in violation of regulations related to the license and qualification of their medical experts and may yield rather than document it. I'm not convinced, it would be easy for them to hire physicians to do their work, not everybody is Hawkeye Pierce, and it would pose much less risk of class action suits.

Question the Review Process

Here is another approach to questioning the qualifications of the people the insurance companies use for these decisions.

Call the insurance company and ask to speak to the HIPAA Compliance/Privacy Officer; by federal law they have to have one.
Ask the HIPAA officer for the names and credentials of every person accessing your record to make the decision to deny your care. Again, by law, they must have a complete list of people accessing your record and you have a right to that information. That's what's buried in or hidden behind the HIPAA Consent Form you sign without reading every time you go to a healthcare provider.
The theory is that insurance companies often use low-wage high-school grads working from lists of "criteria words" to routinely deny care. Since they do not want to admit this, they may reverse the decision rather than release the information.
Any refusal by an insurance company to release information they are required to provide should be reported to the U.S. Office of Civil Rights (assuming it is still operational) as well as your state insurance regulator. Keep thorough, accurate records of everything for yourself, your attorney if it goes that route, and the regulators. Do not include your emotional state in your notes, they need to be strictly "just-the-facts." Calling names or including indications of how angry you are will likely work against you.