| When you buy a health insurance plan, you | | | | journals that prove it is safe or effective. It will |
| expect it to be there for you when you need it | | | | also help your case if you are able to find proof |
| most. In exchange for your monthly premiums | | | | that other local health insurance companies cover |
| and a certain deductible and co-insurance | | | | a treatment, or that your insurer covered the |
| percentage, you are purchasing financial security in | | | | same treatment for other patients in the past |
| the event of a severe health issue. Treatments | | | | - Get written documentation from your doctors |
| for major conditions like cancer can cost millions | | | | and medical offices. Your claim is more likely to be |
| of dollars. In an attempt to maximize their | | | | approved upon appeal if medical professionals |
| revenues, health insurance companies seek to pay | | | | agree that a particular treatment is medically |
| out as little in claims as possible. While detecting | | | | necessary or acknowledge that a billing or coding |
| health insurance fraud is a laudable goal (and | | | | error occurred. If you filed an out-of-network |
| catching medical fraud helps everyone save on | | | | emergency claim, those doctors (along with your |
| individual health insurance premiums), innocent | | | | medical records) can prove that there was no |
| people get caught in the crossfire. | | | | in-network treatment provider available. |
| There are several reasons why your health | | | | - Keep track of all discussions with your health |
| insurance claim may be denied: | | | | insurance provider: date, time, and the person you |
| - The procedure, treatment, or medication is | | | | spoke with. Find out exactly who can help with |
| specifically excluded from your health insurance | | | | your appeal, and send it to that person directly. |
| policy. | | | | This will make the claim process move faster. |
| - The health insurer considers the procedure to | | | | - If you have a chronic illness, the health insurance |
| be an experimental treatment; as a result, they | | | | claims process can be extremely complex. |
| refuse to pay for an unproven treatment. | | | | Advocacy associations--both general and |
| - You visit an out-of-network hospital emergency | | | | disease-specific--can answer your questions and |
| room or clinic. | | | | help you file. Failing that, it may be worth it to hire |
| - There is a clerical error; for example, an | | | | a medical billing advocate. They specialize in |
| incorrect address or diagnostic code. | | | | navigating through health insurance bureaucracies, |
| Far too many people are unaware of their options | | | | and their hourly or percentage fee may be worth |
| after a claim denial. Instead, they give up--a | | | | the additional peace of mind. |
| decision which costs them tens of thousands of | | | | - Contact your state's insurance department if |
| dollars. Health insurance companies, including major | | | | you have individual health insurance or health |
| providers like United Healthcare, have appeal | | | | insurance through a small- or medium-sized |
| procedures. Sometimes it will take multiple appeals | | | | employer (meaning that you are covered directly |
| for you to get your claim covered by your health | | | | through a health insurance company). Forty-five |
| insurance. Persistence is well worth it! Follow these | | | | states have independent external review boards, |
| tips to increase the likelihood of your appeal | | | | which will review your claim if all or your internal |
| succeeding: | | | | appeals have been exhausted. |
| - Make sure to file an appeal before the deadline | | | | - You may have less recourse if you receive |
| (usually 30 to 90 days), but don't rush. Build your | | | | health insurance through a large corporation that |
| case and inquire for information without revealing | | | | self-insures. Since the firm pays medical claims |
| your intentions; some health insurance companies | | | | itself, it is not subject to state insurance laws. |
| will take that statement as an appeal in itself, | | | | However, check your plan summary for any |
| making it far less likely that their decision will be | | | | external appeal reviews: the majority of |
| reversed. | | | | companies have them. |
| - Do your homework. If a procedure is considered | | | | (Image: Steve Weaver under CC 2. |
| experimental, find research in reputable medical | | | | |