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You can appeal insurance claim denial

More and more health plans are denying claims, say consumer advocates who offer guidance for handling medical bills. • First: Don't panic. Many claims are rejected for glitches that can be sorted out. Do not pay a bill without making some calls. • "A claim can get kicked back for any number of reasons, and yes, it can be very annoying," said Nancy Metcalf, who focuses on health issues for Consumer Reports magazine. • Call your health plan and find out why your claim was denied. It's important to get specifics, said Sean Shaw, insurance consumer advocate for Florida. • Many denials are linked to correctable errors, Metcalf said. Billing is based on codes that stand for different medical problems. The wrong code entered accidentally could trigger a denial. An incorrect patient ID number also could be at fault. • Though some problems are easy fixes, others take time and considerable followup on your part.

. Make a file to keep paperwork related to the claim.

. Maintain a phone log that lists the date and time of every call you make related to the bill, the person you spoke with and notes on the conversation.

. Shaw suggests following each phone call to your health plan with a letter — e-mail is not recommended — providing the details of your discussion and your understanding of what will happen next. Always keep a copy for yourself. These letters will be useful if you appeal the denial.

. Every health plan has an internal grievance process. Find out how to file an appeal and get on it right away so you don't miss a deadline.

. The government insurance programs, Medicare and Medicaid, have their own internal review processes. Again, call the programs to learn what to do.

. Florida provides another option for people in managed-care plans who lose an appeal: bringing the case to the state's independent Subscriber Assistance Program, which examines roughly 150 cases a year, said Tom Warring, chief of Florida's bureau of managed health care. Warring said the SAP reverses about half of the denials. Contact SAP toll-free at 1-888-419-3456.

. Report an insurance-related problem to the Consumer Helpline at the Department of Financial Services (toll-free 1-800-342-2762). It fielded about 300,000 calls last year, Shaw said.

. Keep your doctor's billing office in the loop. After all, you may need their help with additional documentation. You also don't want them to give an unpaid bill to a collection agency.

. If all else fails, here's the deal: You are legally stuck with the bill. But the billing office may be willing to negotiate a lower payment or forgive the fee altogether. At the very least, you should be able to set up a payment plan.

You can appeal insurance claim denial 03/25/09 [Last modified: Wednesday, March 25, 2009 5:22pm]

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