Winning the Appeals Process Against Your Health Insurance Company
Gather your evidence: Review all paperwork regarding your case immediately! You may want to sit down with someone from your Human Resources Department for some guidance.
At this time, the HR manager can let you know whether you are on a self-funded plan.
This type of plan is where the employer is actually paying your claims and merely using the insurance company for administrative purposes (these claims may need to be taken to a federal level instead of a state level).
This will make a big difference in how you approach the appeals process.
Ask questions until you are sure you understand everything: Be sure to call your insurance company, when you are calm, to help clarify what you may not understand.
Take notes and request something in writing explaining why you were denied within a reasonable amount of time.
Request an itemized bill: You can get thisfrom the doctor or hospital.
Analyze every charge if you have not been asking for copies of your bills or medical records on the way.
You may have to ask your doctor or billing department for guidance since some of these charges might be difficult to decipher.
If there are charges on these bills for services not delivered, notify the doctor or hospital immediately to get the bill adjusted.
Then, notify your insurer.
Make an appointment with your doctor: Get your doctor involved from the beginning by offering to pay for an appointment to be consulted.
Let them know why you were denied.
Bring in all documentation and see if he/she can talk to the medical director that denied you, and write a formal letter the insurance company.
Contact your state's department of insurance: In some states, it may be known as the department of managed care.
You can find this information at http://www.
statehealthfacts.
orgEvery state has different procedures when it comes to assisting consumers through the health insurance appeals process.
The more information you gather before you contact the state department of insurance, the better they can assist you.
If you are covered under a self-funded plan, you may need to appeal with the Department of Labor's Pension and Welfare Benefits Administration.
Notify your local medical society: Physicians need to know if your insurance is not covering a certain procedure.
If your claim is constantly coming up, the local medical society might want to write a letter to the insurance company as well as the notify the rest of their members (ask your doctor to help you contact their local medical society).
If you are getting denied, your doctor is also getting denied, thus they might encourage doctors not to participate in that particular insurance.
If this happens, and a vast amount of providers drop that insurance plan, in extreme cases, the plan will "cease to exist.
" Remember, the providers make the insurance plan, and without participating providers, there is no insurance plan.
Get an attorney involved: If you are lucky to consult an attorney throughout the whole process, you might want to consider this, but it may be costly.
However, if you do not have the funds, hire one as a last resort, but be sure this attorney has experience in dealing with health insurance companies.
Any attorney will not do!
At this time, the HR manager can let you know whether you are on a self-funded plan.
This type of plan is where the employer is actually paying your claims and merely using the insurance company for administrative purposes (these claims may need to be taken to a federal level instead of a state level).
This will make a big difference in how you approach the appeals process.
Ask questions until you are sure you understand everything: Be sure to call your insurance company, when you are calm, to help clarify what you may not understand.
Take notes and request something in writing explaining why you were denied within a reasonable amount of time.
Request an itemized bill: You can get thisfrom the doctor or hospital.
Analyze every charge if you have not been asking for copies of your bills or medical records on the way.
You may have to ask your doctor or billing department for guidance since some of these charges might be difficult to decipher.
If there are charges on these bills for services not delivered, notify the doctor or hospital immediately to get the bill adjusted.
Then, notify your insurer.
Make an appointment with your doctor: Get your doctor involved from the beginning by offering to pay for an appointment to be consulted.
Let them know why you were denied.
Bring in all documentation and see if he/she can talk to the medical director that denied you, and write a formal letter the insurance company.
Contact your state's department of insurance: In some states, it may be known as the department of managed care.
You can find this information at http://www.
statehealthfacts.
orgEvery state has different procedures when it comes to assisting consumers through the health insurance appeals process.
The more information you gather before you contact the state department of insurance, the better they can assist you.
If you are covered under a self-funded plan, you may need to appeal with the Department of Labor's Pension and Welfare Benefits Administration.
Notify your local medical society: Physicians need to know if your insurance is not covering a certain procedure.
If your claim is constantly coming up, the local medical society might want to write a letter to the insurance company as well as the notify the rest of their members (ask your doctor to help you contact their local medical society).
If you are getting denied, your doctor is also getting denied, thus they might encourage doctors not to participate in that particular insurance.
If this happens, and a vast amount of providers drop that insurance plan, in extreme cases, the plan will "cease to exist.
" Remember, the providers make the insurance plan, and without participating providers, there is no insurance plan.
Get an attorney involved: If you are lucky to consult an attorney throughout the whole process, you might want to consider this, but it may be costly.
However, if you do not have the funds, hire one as a last resort, but be sure this attorney has experience in dealing with health insurance companies.
Any attorney will not do!
Source...