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August 4th, 2014 by NerdWallet
By NerdWallet Health health finance expert Christina LaMontagne
How can I fight a denied claim from my health insurance company? Before my hip surgery, I confirmed with both my doctor and my insurance company that the surgery would be covered. Now my insurance company has denied my claim – how can I appeal my $50,000 medical bill?
Appealing to your health insurance company is within your rights, but your chance of success will depend on your policy, the exact procedure you underwent and the wording of the denial on your health plan’s explanation of benefit.
Here is the basic process I would recommend, broken down into three steps.
1. Obtain the correct documentation
Call your doctor and ask for documentation of his or her conversation with your insurance company. Surgery usually requires authorization from your insurance before treatment, and it is the surgeon’s or hospital’s job to obtain it.
Your doctor should provide detailed documentation that includes the name of the person the doctor or hospital spoke with, when the conservation took place and what was said. If the surgery was pre-authorized, your doctor should be able to provide a written record.
Next, contact the insurance company and ask why your claim was denied. Your request should be in writing and should be sent via certified mail to a specific person. The insurance company must provide you with a reason for the denial—you are entitled to it. Once you have this information and have reviewed it, you will better understand the situation and what steps you must take.
2. Write your appeal
Next, you can write an appeal and ask for what is called a “retro-authorization.” You need to establish the medical necessity for the procedure as documented in your medical records.
If your treatment was experimental, you may need to provide supporting evidence to demonstrate your previous less-radical-but-unsuccessful treatments, a list of medications that did not work or that provoke side effects and physical therapy or any other modalities that were not helpful. A medical report from a specialist determining that the only treatment option was this specific surgical procedure should be included. Your surgeon should provide you with this documentation and file an appeal as well.
3. Send your appeal
Send your appeal via certified mail or return receipt, with a copy going to the doctor. If you are insured with a PPO plan, I would also send a copy to the Department of Insurance, Department of Corporations or Insurance Commission (depending on what state you live in). This may delay action on your account for 60 to 90 days while it is investigated, but you may get a better outcome.
What if you’re denied?
Depending on the state you live in, you may be able to file a complaint or ask for an independent review through the insurance commissioner’s office. Check your policy, too, for steps to file a second-degree appeal. If all else fails, you should try to negotiate lower fees, especially if neither the surgeon nor the facility checked on the requirement to get an authorization.
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