Until a few years ago, if your health insurer denied a claim, it was complicated and frustrating to fight the decision. But thanks to the federal law known as the Affordable Care Act (ACA), it has now become much easier to win an appeal. The law requires that any time an insurer denies an insurance claim or payment for a medical service, it must do so in writing and spell out the appeals process. It also requires that even if you lose the appeal, you can still appeal that decision to a noninsurance company–affiliated third party (such as a state insurance department). Since passage of the law in 2010, appeals have increased, and a greater number of them (up to 60%) are now won. Still, it’s not a slam dunk that you will prevail if you appeal an insurance claim denial.

To increase your odds of winning…

  • Know what’s covered. Your health insurance is like money in the bank that’s set aside for your medical care. But surprisingly most people do not know what is and is not owed to them (or “covered”) by their insurance plans, including private employer-provided insurance, Medicare, Medicare Advantage or Medigap plans. Later, these same people are surprised when they receive an unexpected bill. For example, you might assume that a routine tetanus shot would always be covered by Medicare. Not so. In fact, Medicare will cover a tetanus shot only if it’s deemed medically necessary (for example, you’ve stepped on a rusty nail). My advice: If you don’t read your health insurance policy, then call your insurer to confirm coverage (or coverage limits) before you receive any medical procedure.  
  • Be on the lookout for errors. Several years ago, I received an $8,000 bill when my insurer said that a second night’s hospital stay wasn’t covered. As it turned out, the insurer mixed up my claim file with my wife’s, and the error was corrected. This just goes to show that many claims are denied because of administrative errors. Other times the doctor or hospital may have used the wrong code when submitting the claim. If you are turned down, call your insurer and ask for the code that was submitted. Then call your doctor or hospital to see if that is the correct code for the service that was provided. Your provider can resubmit the claim and include a letter of explanation that describes what you had done. Helpful: Ask your doctor’s office or hospital billing office for copies of everything your doctor or hospital has submitted to the insurer in case you need to file an appeal.
  • Be smart when going out of network. If your insurer requires you to use certain in-network doctors or facilities and you get a service outside of this network, you will likely be charged for all or part of the cost. However, you can win that denial if you can show that the service was necessitated by an emergency or your insurer’s network could not meet your medical need. I once helped a family find an out-of-network surgeon who was one of only two doctors in the US who performed a pediatric brain procedure needed by their son. The claim was initially denied, but they submitted an immediate appeal with supporting documentation about the doctor’s skill and the child’s needs. The claim—almost $500,000—was approved! My advice: Get out-of-network services preauthorized. Gather all the supporting evidence you can to back up your request and/or enlist all the medical experts you can find to support you.

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