How to Fight and Insurance Denial or Underpayment

Strategies For Fighting an Insurance Company Denial

Get Organized and Be Persistent

Chances are you may have been to a doctor or other health care provider and have either submitted a medical claim yourself or had the office submit it for you. Then you get your response from your insurance company and medical claim you’ve submitted has come back to you either denied or partially paid. There can be many other messages on your Explanation of Benefits that are at best confusing and at worst utterly frustrating. So what can you do? Here are a few tips to keep in mind when dealing with your insurance company that can give you a better chance at getting them to pay you what they are contracted to pay.

The number one advice I tell people is to start a very detailed paper trail. Never get on the phone with an insurance company without ending the call and getting the first name, first initial of the last name, and a reference number for the call or the reps ID#. They may even tell you, “we don’t keep a record of the call.” This is absolutely not true.

I usually call twice for the same issue so I can get someone else on the phone. You would be amazed at how many times I have called on behalf of the same patient for the same date of service, and received a completely different story about what has happened and what I am supposed to do to resolve the issue. Again, with attention to details, with names, call ID numbers and call summaries, you can begin to construct your paper trail should you need to file a complaint later on in the process.

If you are not satisfied with the results on your level one calls, get a supervisor on the phone. Demand it! You want to get as high up the chain as you can to get resolution. I always recommend also to write a letter and send it certified as well, with a summary of whatever issue you are having and what you would like them to do. Ask that the insurance company provide you in writing with the name and credentials of the person who reviewed your claim to make sure a qualified expert is actually reviewing it.

Always remember to remind whomever you are speaking to that you are a customer of the insurance company and you want to be treated as such. I find it remarkable that insurance companies often leave you confused and in the dark about what they are doing so that they can take longer to pay your claims and resolve your issues. Don’t be afraid to tell them that waiting another 30 days for example is unacceptable. Be a squeaky wheel. Tell them that you want to hear more things like “Let me find a way,” or “I’m going to make this right,” instead of their standard, “Our policy is,” or “unfortunately,” or “I’m sorry that’s all I can do.” Make them go the extra mile

If you work for a company that provides your the health insurance, I always recommend to our patients to get in contact their Human Resources department and find the person who is the liaison with the insurance company. Let them know what is happening right away. You might be very surprised to know you are not the first person who has been having problems. Your HR representative will definitely have a contact in the insurance company that is many levels above where you will get by calling the number on the back of the card. They can often exert the leverage of the whole company as a customer of the insurance company to get you results. In an extreme case, I heard a story of a patient whose HR department realized there was a pattern of stalling tactics and denials and they dropped that company and took their business elsewhere. If you do not have an HR department, contact the broker who helped you get the plan. They can also exert influence as well.

If you were denied for medical necessity and have already appealed to the insurance company and they still have denied you, utilize the external appeal process in your state. Every state has an arbitration process and although it requires putting your case together yourself, it is worth it. You can have your case reviewed by non-insurance company experts. Have your paper trail ready.

You can also file a complaint with your state’s insurance commissioner for issues that relate to the amount of time your insurance company is taking to process your claims. Here is a link to the complaint form for NYS. Remember that insurance companies have to abide by what is called “timely filing” usually around 30-45 days. – In New York, NYS Insurance Commissioner – for timely filing

If your company reduced it’s payment with some type of UCR code, say for example they tell you something like, “Your provider is charging you an excessive amount of money for these services, and we have discounted the fee accordingly”, and you find yourself with a big bill, reach out to your state’s attorney general office to the consumer protection office. In NYS, the link to the complaint form is here. Yu have a right to knopw how the insurance company actually calculated this amount. ASK for it in writing, they have to provide it to you by law in 30 days.

I have found that people in this offices to be very informative and friendly in guiding you through the process of filing a successful complaint. Not many people utilize their state resources to get results, and they can be powerful tools in your arsenal. – In New York, NYS Attorney General Health Care Bureau Complaint Form

Insurance companies often appear to utilize a variety of tactics so that they can delay paying your claims for longer periods of time. Make no mistake, an insurance makes a lot of money by working the float on the interest as the money stays in their bank accounts. Every day they take to pay your claim is another day they make interest on the money while it is in their bank. Be a squeaky wheel and exercise all of your rights to make sure your insurance company is processing your claims according to the contract you have purchased, and in a timely manner.

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