How to Appeal Denied Health Insurance Claims

[Jen]

Hi everyone!

Happy Monday!

I hope you all had a nice weekend.

Here's a recent story we posted on successful tips on handling denied insurance claims. 

READ HERE. 

Did we miss anything? Do you have a story/tip you could share with us? 

Let us know!

[AmandaSingleton]

Hi Jen:   Thanks for posting this article!  A little bit of knowledge and a lot of organization can make all the difference in a successful insurance appeal.    I would chime in that keeping detailed notes of phone calls (including times of phone calls, the names of everyone you speak with, and reference numbers for the call), following up in writing always, and making sure that you meet every deadline laid out in your policy can make or break the claim.   As a former in-the-trenches attorney for insurance carriers and as a current advocate who handles insurance appeals and grievances, the paper trail is critical.  

For private insurance, make sure to ask for a full copy of the policy.  It should set forth the rights and responsibilities of an insured.  If you have questions about why a claim was denied, you may wish to request a complete copy of the claim diary and notes from the adjusters who handled your file.  This may give a lot of insight into the denial. 

Also, your state's laws may have additional protections or requirements they have if you want to pursue the claim.  For example, in Florida, our laws have notice requirements before we file lawsuits for insurer violations. 

Finally, for caregivers who are handling insurance claims and appeals for someone else, it is crucial that you have the proper paperwork to speak on behalf of the insured person (for example, a Durable Power of Attorney that specifically lays out powers like "preparing, signing, filing, and appealing" Medicaid or insurance claims). 

I'd love to hear input from other caregivers who have had to appeal an insurance claim for someone else.  Was the denial reversed?  What did you wish you knew, looking back?  My post is running long, but I'd be happy to share a few stories as well. 

[GailL1]

@AmandaSingleton @Jen 

I mean no disrespect to the experts here but think there is one very important step that is getting overlooked especially where we have so many different types of health care coverage options. 

It is very important for people - individuals or caregivers - to know is what type of coverage the insured has -

Medicare

Medicaid

Medicare with Medicaid

Medicare with a host of other 1st or 2nd payers -

ACA Individual Marketplace Health plan

Employer Coverage

OR Something else like a Short-Term Health Insurance Policy

[LaurieR72785]

Amanda, I appreciate your article and the fact you have experience. Perhaps you can provide me some direction.

My wife spent hours trying to pick up health coverage last years after my state retirement health care plan diverted to Medicare. In her hurry she quickly signed an application through her agent and all was fine until claims rolled in for her hip replacement surgery this June. Every claim was scrutinized and delayed to the max. Then the issuer notified her the policy was under review for recession because she not checked it for pre-diabetes.  An honest mistake but more intriguing is that she took metformin BEFORE she assumed this policy and they have diligently paid claims and taken premiums since day one. So, why wasn't this addressed early on-particularly with the same fervor they challenged the hip replacement claims? AND they already approved her surgery-they now want to deny. Her primary care physician and ortho-surgeon both wrote letters that the pre-diabetes had no relation to the hip surgery. We are, of course, appealing, and we are honest, so we have asked for a review of any pre-diabetes claims and would discuss recompensing the company. If they deny the appeal what direction could you suggest?

[GailL1]

@LaurieR72785 

May I ask if this is what is deemed to be a short term health insurance policy?

Doesn't sound like it is an ACA individual marketplace policy.  If it is, most likely it was appealing to her because of the premiums especially if she was in the so-called "subsidy cliff" - meaning that the combined income of you both was over 400% of the Federal Poverty level and thus she did not qualify for a premium tax credit on an ACA individual policy and thus this type of (ACA) policy was very expensive.

Here is an article about those Short-term health insurance policies if my assumptions are correct.  What they are / what's the appeal / Pros & Cons

Health Insurance.org - Short-term health insurance by state 

If she took metformin before the policy was issued - but didn't check diabetes as a pre-existing condition - did she list it as one of her medications on the health form?  If it is one of these Short-term health policies, they can resend the policy if they find that she was untruthful on the health form. 

If I am correct in my many assumptions here, my best advice to you before doing anything further is to READ THE POLICY to figure out what kind of policy she actually has. 

You might find more or different replies if there are any on the "Medicare and Insurance" AARP Community Board than on this "Caregiving" AARP Community Board.

[LaurieR72785]

Gail, sorry this response is so late, I apologize. I am new to the site and thought I would get an alert to any notifications.

We will have to read the policy better to verify your assumptions. She did search for reduced policy premiums because the costs were so high and discussed her meds and her health with an independent agent- and he then hooked her up with this plan. Claims she told him about the Metformin. She was only advised recently by her doctor that she was pre-diabetic but did not think that was a pre-existing condition. However, we see now it is listed beside Diabetes on the App and she foolishly and quickly signed the electronic application without verifying the information.  

She is applying for Medicare now since she will be 65 in February. 

[AmandaSingleton]

Hi @LaurieR72785:  I'm sorry to hear that your wife and you have been going through all of this!  You sound like you've taken the correct first step -- appealing the denials and possible rescission.   Do you have a professional on board to help you with the internal and external appeals processes and to help you challenge the rescission?  You may wish to engage an attorney in your state of residence to guide you through this.   Your local or State bar association should have a referral directory that will point you in the direction of a firm that practices this area of law.  Be prepared to discuss the mistake that led to the pre-diabetes not being disclosed/omitted in any application documents.  And while I can't give specific legal advice on this forum, I am going to copy some information below that may be useful.  All the best of luck, Laurie!

Here are a few links that discuss insurance claim denials and policy rescission:

https://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/curbing-insurance-cancellatio...

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/External-Appeals

https://www.healthcare.gov/health-care-law-protections/cancellations/

[GailL1]

Since this AARP article is directed to Caregivers, It might  be an excellent place to stress and describe the importance of having a healthcare directive or healthcare POA or an AUTHORIZED Representative under Medicare.  The later is assigned differently than a health care directive or healthcare POA.  Since Medicare now has a good individual personal site under MyMedicare, assigning an AUTHORIZED Representative by a person on Medicare is relatively simple and can be done sooner than later - meaning don't wait for necessity.

With privacy issues paramount in today's society, it will serve people well to go ahead and assign a representative for themselves, after asking the designated person, of course, because it is not easy if for some reason the covered person cannot verbally give permission to speak to another about any claims problem, no matter which type of coverage and specifically when there is a caregiver involved.