The Best Way to Win an Insurance Appeal
The punchline is, “Not to have to do one.”
We’ve posted before on Medicare insurance appeals for Part A/B, Medicare Advantage, and Part D. We’ve even posted on doing battle with insurance companies. The fact is, insurance appeals are time consuming and can feel like doing battle. If you can avoid one, why wouldn’t you? How likely is that you’ll have to appeal an insurance/Medicare decision? I don’t have the statistics, but I suspect that most will do it in their lifetimes. If you haven’t had to appeal, ask a couple of people. Odds are they have.
If you believe that there’s a chance that you’ll want to appeal in the future, why not reduce that chance by spending some time understanding your coverage and what it takes to avoid the calls and letter writing? Consumers Union and The Henry J. Kaiser Family Foundation did, “A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, 2005 Update” that’s all about how to deal with problems with your insurance. But the gem in there is, “a checklist for diagnosing your coverage”
The checklist covers many of the triggers that will put you in a situation for an insurance appeal. For instance, it asks you to check the medical services for which you need a referral from your primary-care physician. Sure you may know some of them, but if you dig through your insurance coverage forms and identify them in advance, you’ll reduce the chance of a denial of coverage.
There are a number of checklists that you’ll want to fill out:
- My primary-care physician has the following requirements for obtaining referrals
- My primary-care physician can refer me to specialists who
- I have reviewed the Exclusions and Limitations section in my Evidence of Coverage. My health plan will not pay for, or limits, the following services
- My plan will cover services at the following hospitals
- What should I do if I need care while I am out of my plan’s service area?
- Although I can use out-of-network doctors for most services, I cannot use out-of-network doctors for the following services
- If I use out-of-network providers, I will pay
So, here’s what you need to do:
- Print the form a checklist for diagnosing your coverage
- Fill out what you can from reading your plan
- Call your plan provider for the information you don’t have
This won’t guarantee that you won’t have a reason to appeal, but it should give you some peace of mind that you’ve reduced your chances a denial.
And, if you do have to appeal:
- Turned down for a Medicare Part A/B medical expense? Appeal! Here’s how
- How to Appeal Medicare Advantage/HMO coverage denial
- How to Appeal Medicare Part D prescription drug coverage denial
- Doing Battle with Insurance Companies
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