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If you suspect problems, contact your insurance provider.


Grievances are complaints about service; Appeals are a procedure used when the plan denies or terminates a service.


The appeal process begins when you write the letter asking for reconsideration of the HMO's decision.


Tell your HMO that you will go to the local and national press if the problem is not resolved by a certain date.


Sign and date each letter and retain a copy for your own files.

Insurance Claims and Denials


The following excerpt is taken from Chapter Ten of Hydrocephalus: A Guide for Patients, Families, and Friends by Chuck Toporek & Kellie Robinson, copyright 1999 by O'Reilly & Associates, Inc. For book orders/information, call 1-800-998-9938. Permission is granted to print and distribute this excerpt for noncommercial use as long as the above source is included. The information in this article is meant to educate and should not be used as an alternative for professional medical care.

You can obtain maximum benefit from your insurance policy by keeping accurate records and challenging any claims your provider denies.

  • Make photocopies of everything you send to your insurance company, including claims, letters, and bills.

  • Pay bills by check, and keep copies of all canceled checks.

  • Keep all correspondence you receive from billing and insurance companies.

  • Write down the date, the name of the person contacted, and the details of all telephone conversations related to insurance.

  • Keep accurate records of all medical expenses and claims you submit.

Establish a contact person

If you suspect problems or if complications arise, your first step should be to contact your insurance provider. On your initial call, you will be transferred to the first available representative. If, for whatever reason, you don't like the person you are speaking with, ask to be transferred to a different representative. Insurers can sometimes assign you a specific person to review your claims and answer any questions you may have regarding benefits.

When you reach the representative who will be handling your claims, you should write down the representative's name and her extension number. Having someone who is familiar with your case history will save countless hours of having to re-explain your situation each time you call. By developing a cooperative relationship with your insurance representative, you will help to make things run more smoothly and eliminate at least one element of stress.

I was having trouble trying to communicate my son's needs to the representative on the other end of the phone one day. After having taken Brian from doctor to doctor, and getting a cranky representative on the other end of the line, I was about to lose it. I told her that my son has a very serious condition, which requires specialized care and treatment. She just didn't get it.

My solution was to mail her a nice letter, introducing myself and explaining hydrocephalus to her, in brief. I also included a couple photos of Brianone of him wearing his soccer uniform, the other of him lying in a hospital bed, shortly after a recent shunt revision. I received a call from her the day she received the letter and photos, and our relationship changed instantly. From that point forward, she's been Brian's advocate on the inside.

If you are insured through your employer, the human resources (HR) representative at work is another person you can turn to when you have questions about your medical coverage. Your HR contact should be familiar with all the details of your health plan. In many cases, your HR representative can act as a liaison between you and the insurance company in the event of any billing discrepancies or denied claims.

Right to appeal denials

You have the right to appeal claims denied by your insurance company. Don't be afraid to ask questions and be persistent.
  • Keep original documents in your files, and send photocopies to the insurance company with a letter outlining why you think the claim should be covered. Sample appeal letters are provided for your use at the end of this chapter.

  • Demand a written reply.

  • Talk to your state insurance commissioner (or other office with similar duties) to learn how to file a complaint. Find out what power the state has to help you resolve your dispute.

  • Contact your congressional delegation. All senators and members of the House of Representatives have staff members who help constituents with problems.

  • Take your claim to small claims court or hire an attorney skilled in insurance matters to sue the insurance company if you've exhausted all other means to resolve the dispute.

Grievances and appeals

Problems fall into two broad categories: grievances and appeals. Grievances are complaints about service, such as a rude doctor or waiting too long for an appointment. Appeals are a procedure used when the plan denies or terminates a service you think you need, or refuses to pay for care you've already received.

To file a grievance with your HMO, take the following steps.

  • Talk to the person with whom you had the problem to see if it can be resolved.

  • Call the member services department and explain the problem. Make sure to write down the date and time, the phone number, and the first and last names of the person with whom you spoke. Keep a record of what was said and note the person's direct phone line number.

  • If the problem is not resolved, write to the plan to ask for an investigation. Different states (as well as each plan) have varying amounts of time they allow for response. To find out your state's regulations, call your state department of insurance.

  • Call frequently to ask about the status of the investigation.
Take the following steps to begin the appeal process.
  • First, make an appointment with your primary care physician to explain your problem and ask for help. For example, if the problem is refusal to refer you to a specialist, ask her for the reasons (medical and economic) why she refuses to refer you. Tell her clearly why you think the referral is necessary. You may just change her mind.

  • Your plan is required to notify you in writing about any denial, reduction, or termination of services. If you have not received it, ask for a written response explaining the medical and financial reasons for refusing the treatment or payment. Demand that the names of all persons involved in the decision, including any "medical advisors" and their qualifications, be included. You should also ask for articles from the medical literature that support the plan's position. If the administration can't or won't provide any, your case is strengthened. In the meantime, locate articles that support your position and attach them to your appeal.

  • Take the written denial to your primary care doctor to ask her to write a letter of appeal on your behalf. For instance, if your doctor thinks you need a sophisticated diagnostic test, but the HMO refuses to pay for it, she might be willing to go to bat for you. If she refuses, try to get the plan to send you to another doctor in the network for a second opinion. If they refuse, or if you feel it is important to get an out-of-network view, pay for an independent second opinion yourself.

  • Write a letter of appeal yourself and send it to the insurance carrier and your employment benefits manager. Send the letter by certified mail and get a receipt with the signature of the person who accepted the letter. The letter should include a clear and concise definition of the problem, as well as your name, policy number, doctors' statements, lab results, and other pertinent materials. Make sure to state in the letter what action you want the group to take to resolve the problem. Don't delay writing the letter: your right to start an appeal may expire in as few as thirty days. Keep copies of all correspondence for your records.

  • The appeal process begins when you write the letter asking for reconsideration of the HMO's decision. The plan generally must complete this reconsideration of their decision within sixty days. Keep calling to find out the status of the appeal. If you need an expedited appeal because your health could be in peril if you wait the sixty days, request it in writing, and enclose supporting documentation from a doctor.

  • Consider hiring a medical claims assistance professional. She will organize paperwork, research appeals procedures, and gather medical reports.

  • To go outside the HMO for help, send a copy of your written complaint and related documents to the state insurance commissioner as well as your local and state medical societies.

  • Send your appeal to your state senators and representatives, and your U.S. senators and representatives. These elected officials have staff members who try to help their constituents. In addition, it helps them as they ponder how to vote on health care related bills to know the struggles that members of managed care organizations sometimes face.

  • If you are insured through your place of employment, contact the benefits department or union benefits manager to see if they will support your position. If enough problems arise, your company may threaten to find another health care plan, and this threat may help resolve your problem favorably.

  • Don't pay a bill that your insurance or Medicaid should pay, even if the claim is taking a long time going thorough the system, and you are being hounded by collection agencies. Many public assistance programs, such as Medicaid, have no provision for reimbursing you once you have paid. Keep your providers informed about your efforts to get payment.
A lawyer suggests:
  • If you still have the problem, tell the HMO staffers that you will go to the local and national press after a certain date if the problem is not resolved. Sometimes the threat of bad press will help, while other times it hurts.

  • Contact Physicians Who Care, an advocacy group of more than 3,500 doctors. Call their complaint hot line (1-800-800-5154) and leave a message about any abuse or ill effects (denial of access to specialists or procedures, reimbursement problems, denials of needed treatments, etc.) resulting from your HMO care. They will contact you by letter within a week. All information is confidential.

  • Contact a consumer advocacy group such as the Consumer Federation of America's insurance group at (202) 547-6426. Or the Center for Patient Advocacy at 1-800-846-7444 or online at http://www.patientadvocacy.org/. Families USA provides a list of state agencies regulating health care and information on state managed care laws at (202) 628-3030.

  • Contact the local media, including newspapers, and radio and television stations. Nearly all forms of media have a writer or reporter who covers consumer complaints to help people in their community resolve their problems.

  • Get a lawyer. Lawsuits can take years, and involve endless maneuvering. Most people who go through the process say they underestimated how hard it would be, especially to relive the medical trauma. And then, of course, there is the possibility that you have a legitimate case but will be unable to prove it in court, or state laws may limit your right to collect. Nevertheless, legal help may be your last chance to get the care you need. Contact your local bar association to find an attorney skilled in insurance litigation.
Try to remember that many managed care organizations are used to passive consumers. Proactive, savvy HMO consumers can get excellent and comprehensive health care from an HMO if they choose wisely and have a good relationship with their doctor. Even when you are happy with yourcare, check the status of your HMO periodically, because they are being bought, sold, and merged at a rapid rate. Make sure that economic forces have not changed the quality of the care provided by your plan.

Sample letters of appeal

The following sample letters are provided for use in appealing denied claims or services by your insurance company. The First Level Appeal letter should be sent out upon notice that a particular service or claim has been denied. The Second Level Appeal letter should be sent either after your initial letter was ignored or if the claim or service was denied a second time.

When sending letters of appeal to your insurance company, it is important that you sign and date each letter, and retain a copy for your own files. Make sure that your full name, mailing address, and phone number are at the top of each letter.


First Level Appeal

Your Name
Your Address
Your City, State/Province Zip/Postal Code
Your phone number

DATE

Name of Insurance Company
Address
City, State/Province Zip/Postal Code

Re: Patient Name
Date of Birth: Month Day, Year
Patient ID/Subscriber Number: xxxxxxxxxx

Dear Sir/Madam:

You recently denied a claim for services provided by (name of provider) on (date of services).

I feel denial of this claim was not justified and I am herewith appealing the denial. Please be aware that my child, (name of the patient), has a serious and potentially life-threatening condition and his/her access to care is critical to his/her well-being.

Please review this claim again. The information is correct (or has been corrected) to reflect the appropriate diagnosis and treatment. If you need a medical report, please inform me within 10 days.

I can be reached at the following telephone number(s):

Daytime: (000) 555-1212
Evening: (000) 555-1212

Thank you for your prompt attention to this matter.

Sincerely,

(Your signature here)


Second Level AppealRequest for Hearing

Your Name
Your Address
Your City, State/Province Zip/Postal Code
Your phone number

DATE

Name of Insurance Company
Address
City, State/Province Zip/Postal Code

Attention: Claims Supervisor

Re:(Name of patient)
Date of Birth: Month Day, Year
Patient ID/Subscriber Number: xxxxxxxxxx

Dear Sir/Madam:

On (date of the first letter), I appealed a denied claim (or service request) for my child. A copy of that claim and appeal letter is enclosed.

I have not heard from you (or the claim remains denied; state reason here). I am herewith requesting a hearing to resolve this matter. I feel that denial and nonpayment of this claim has jeopardized my child's access to health care.

If I do not hear from you within 10 days, I am referring this matter to Consumer Assistance, the State Insurance Commission, and may also seek legal counsel.

In my opinion, you have failed in your obligation to provide acceptable and adequate service. Be assured that I intend to use every available means to get this matter resolved.

Sincerely,

(Your signature here)

cc: Employer Benefits Manager
Physician Hospital Billing Office

Certified Mail


These letters are provided courtesy of Cynthia Solomon, Medical Management Resources, Sonoma, California. They were presented at the Hydrocephalus Association's 5th National Conference on Hydrocephalus, March 26-29, 1998.

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