We are living in an era, in the U.S., when the insurance company often overrides your doctors’ decisions. Less often with traditional Medicare but more with commercial health insurance and Medicare Advantage plans, you may find that a test or procedure your physician ordered is refused payment by your insurer and you are stuck with a huge bill.
A recent report by the Kaiser Family Foundation found that in 2020, 18% of in-network claims were denied by commercial insurers. Don’t passively accept this decision! The denial letter is just the start of the process, not the end.
It has been shown that many of these denials are arbitrary and unjustified. A well-know example is the physician reviewer who admitted in court that he never even read the documentation but rubber-stamped nurse reviewers’ denials.
The denial may be based on a wrong diagnosis code being submitted or a failure of the insurer to consider changing medical standards.
While very few people challenge these denials, almost half the appeals succeed.
What can you do?
First, carefully read the denial letter to try to understand the reason coverage was denied. Yes, the prose is dense, but the insurer must explain its reason for denial.
You may find that before they pay for C, they want you to try A and B first and you have already tried A and B without getting any benefit. You may find that the test or procedure is not considered appropriate for condition X and you have condition Y.
If they have the facts correct and simply refuse payment, you will need to get the ordering doctor involved. They will have to write a letter explaining why they chose to do the test or procedure.
Your first point of contact should be the insurance company’s customer service line. Be sure to get the name of the person with whom you speak. For simple mistakes, they may be able to reverse the denial, but don’t count on it.
Your next step is to write a letter or an email requesting the denial be reversed and saying why. The process should be outlined in the denial letter. If not, it will be on the insurer’s website.
If the response is to still deny the claim, persist. Request an appeal. Indicate in your request that you plan to file a complaint with your state’s consumer protection bureau if the claim is still denied (and do so!).
Finally, outside help is available through the Patient Advocate Foundation and similar organizations.
Illegitimi non carborundum! Don’t let the bastards grind you down!
Edward Hoffer MD is Associate Professor of Medicine, part-time, at Harvard.
What Does The Doctor Say?
By Dr. Edward Hoffer