Skip to main content

4 keys to appealing a rejected insurance claim

By WTOP Staff

TOM MURPHY
AP Business Writer

Keep calm and take notes.

Stay true to this principle and you can improve your odds of successfully fighting a health insurer’s claim rejection.

Experts who help with the appeals process say patients have a 50 percent chance or better of prevailing. They say a winning argument may require heavy doses of research and persistence, but the end result is a decision that can stave off thousands of dollars in medical bills.

Certainly understanding the limits of your insurance, before you seek care, will help you avoid the frustration of having your claim denied. But if you get to the point where you need to appeal, here are some important points to remember.

1. STARTING AN APPEAL

Learn all you can about why your claim was rejected and don’t be afraid to ask questions. If the insurer deems your care to be not medically necessary, request an explanation that includes the insurer’s policy language and any information used in making the decision. Keep records of who you spoke with and when.

“Take down notes and get the language down as cleanly as possible,” said Stephen Parente, a professor of health finance and insurance at the University of Minnesota.

Maintaining a calm demeanor can help you think rationally, and it may make customer service representatives more inclined to help.

Learn the insurer’s appeal process, including any deadlines. A missed deadline can sink an appeal regardless of how strong your case is.

2. BUILDING YOUR CASE

Sometimes a claim is denied due to a clerical error, such as the wrong code being used for a medical procedure. A good starting point is to check with your provider’s billing office to make sure your claim was coded correctly. If something is amiss, you can probably get it cleared up with a few phone calls.

Other cases may require an appeal letter. Your letter should lay out the reasons you believe your care should be covered. Ask your doctor to review your argument and offer input.

A physician can help detail how all treatment alternatives were exhausted before you started receiving the care an insurer deemed not medically necessary.

The insurer will want more than your doctor’s word, so be prepared to include any confidential medical records that support your case.

Consider including medical journal articles that support your argument or detail the effectiveness of your treatment. These can be especially helpful if your doctor is unable or unwilling to work with you on the appeal. Patients can use the National Institutes of Health website www.pubmed.gov to search journals around the world.

Make sure you directly address the insurer’s reason for denying coverage. Not doing so is the biggest mistake people make in filing appeals, according to Cheryl Fish-Parcham, private insurance program director for the health advocacy group Families USA.

Submit your appeals by certified mail so you can document when the insurer receives them and that you met any specified deadlines.

Be persistent. If the first appeal doesn’t work, the insurer should outline additional options that may include an appeal to a medical director who was not involved in the decision.

The insurer also may permit a peer-to-peer review, in which your doctor talks to a physician representing the insurer about your case.

3. GOING OUTSIDE THE INSURER

If you’re not happy with the insurer’s internal review, seek an examination from an independent reviewer. Be mindful of any deadlines for making such a request.

Some patients with employer-sponsored health plans also may be able to turn to their company for help. Companies with self-funded coverage — largely those with 200 or more workers — actually pay the medical bills and hire insurers to administer their plans.

The employer may learn through your appeal that its coverage is more limited than what company leaders intended, said Erin Moaratty, chief of mission delivery for the Patient Advocate Foundation, a nonprofit organization that helps patients with medical bills and coverage denials.

Even if the employer declines to overturn the insurer’s decision, it can be important for companies to be brought into the appeals conversation so that they can consider making coverage adjustments over time.

Check with your human resources department to see if your coverage is self-funded and if they can help you understand the appeals process or put you in touch with the right insurance representative.

4. SEEKING HELP

If you’re not comfortable shaping your argument, or you’re not physically up to it, you have a few options for outside help. Some states offer consumer assistance programs, and your insurer should provide you with contact information for the program in your state.

Help is also available from nonprofit agencies like Patient Advocate Foundation and The Jennifer Jaff Center, which can assist with appeals in cases involving chronic, life-threatening or debilitating illnesses.

For-profit companies like Medical Billing Advocates of America also work on insurance denials. A spokeswoman said its fees depend on the amount of time spent working on the case.

Copyright 2014 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Don’t Settle for Student Loans to Pay for Online Education

By WTOP Staff
Online college programs are becoming a more popular choice for prospective students, with one study finding that more than 6 million students enrolled in at least one online course in fall 2015. The popularity of these courses can be attributed in part to their flexibility with working adults' schedules, students' ability to progress more quickly through online programs and, oftentimes, cheaper tuition. [See 10 low-cost online bachelor's programs for out-of-state students.]Online degrees can be beneficial to many college students, but some studies have shown online learners complete their programs at lower rates than students at traditional brick-and-mortar campuses. Individuals with student loans but no degree comprise two-thirds of defaulted borrowers. Though these numbers are not encouraging, just like for traditional programs, there are ways to reduce how much you'll need to borrow for an online program to ensure you won't become one of these statistics. Don't just settle on borrowing student loans to cover the whole cost of your program and living expenses. Instead, start thinking about how to cut costs and cover your balance in different ways, such as the following. -- Grants and scholarships: Even though you are taking an online course, you can still apply and receive grants and scholarships. But your first step should be to complete the Free Application for Federal Student Aid, commonly referred to as the FAFSA, which will allow you to receive a Pell Grant if your expected family contribution is low enough. The EFC criteria and award amounts are adjusted annually, but the 2017-2018 academic year awards range from $606 to $5,920, which could significantly lower the amount you borrow annually. Your next step is to apply for scholarships. You can start by checking online scholarship search engines, such as the Salt Scholarship Search, College Board's BigFuture and Peterson's. But don't forget to take advantage of local organizations and your school's financial aid office. Both may offer scholarships that you can't find with a national scholarship search. [Review these 10 sites to kick off your scholarship search.]For instance, organizations like the Elks Club, Knights of Columbus or the Rotary Club typically offer scholarships annually to local students. Just because you're going to school online doesn't mean you're ineligible. Visit your local library for scholarship listings, and ask around town. You might be surprised how many local organizations offer scholarships. While these scholarships typically aren't large, every little bit counts. Each dollar you receive in a scholarship is a dollar you don't have to borrow and pay interest on. -- Work-study: Another option for online students may be work-study awards. Not all students enrolled in online programs are eligible, but students at some schools -- including, for example, SUNY Empire State College and Liberty University -- are. Work-study awards are not given upfront like scholarships and grants. In most cases, they are an offer to earn up to the awarded amount if you secure an eligible work-study job. While there is a misconception that all work-study jobs must be on campus, students can work for off-campus, nonprofit or public employers as long as the work is in the public's interest. You may be able to work for a for-profit employer if the job is relevant to your course of study. No matter who the outside employer is, it will need to have an established agreement with your college for you to receive work-study funds. Remember, to be eligible for federal financial aid, you must be enrolled and pursuing a degree or certificate. If you're not working toward a credential, Pell Grants and work-study won't be option, but you may still be able to take advantage of private scholarships -- just be sure to read the eligibility criteria carefully. [Explore what to know about financial aid in online programs.]-- Pay as you go: One of the great benefits to enrolling online is the flexible schedule, which can allow you to complete your college coursework around your responsibilities. But prospective students often overlook using their part- or full-time job earnings as an option for paying for college. Almost 80 percent of college students in 2015 worked at least part time while attending classes, according to the National Center for Education Statistics. By budgeting and thinking strategically about your college costs, you can likely reduce your dependence on student loans by paying a portion out of pocket. Many -- but not all -- online programs are less expensive than traditional programs and often have shorter payment periods. Six, eight or 10 weeks are common course durations. Because of the frequency of payments in an online setting, you may be well-placed to pay as you go and possibly avoid borrowing altogether. Attending college online and avoiding student loans may be challenging, but if you are willing to put in the effort, you can limit the amount you need to borrow. More from U.S. News Q&A: Understanding Student Loan Discharge Eligibility Student Loan Refinancing Isn't Right for All Borrowers
Read Next Story

Related News

Frustration grows in Venezuela as earthquake death toll reaches 1,430

Israel and Lebanon sign framework agreement with US in ‘first step’ toward peace, Rubio says

Trump-endorsed populist poised to become Colombia’s next president as rival challenges vote