Warning: This letter of denial from your insurance company may cause anger, frustration and stress and could be harmful to your health.
Maybe there should be a warning like this on letters from insurance companies when they deny claims. At some point most of us will get a letter like that. Knowing how to respond at that point can save you a lot of grief and help resolve the dispute with your insurance company, in your favor. Here are some tips that might help.
1) Don't call them, write them.
If you ever get hold of a human being on the phone, you'll probably never get to talk to the real decision makers anyway. In a letter you can more calmly articulate your point, it's forwarded to the decision makers and it ensures there's a paper trail of your communications with the insurance company.
2) It might be just a stalling tactic.
Let's face it, insurance companies don't make widgets, they make money. And the longer they can hold on to the money, the more it makes for them in the places they invest it. It could be they're eventually planning to pay, but they just wanted to keep the money in an investment for another week or two and slow down the cash flow.
3) The denial is in the details.
All it takes is one small check mark in the wrong box to cause the insurance company to deny your claim. Double-check to make sure the doctor's office and insurance company coded the procedure properly.
4) Your doctor could be good medicine.
A doctor's opinion often carries more weight than a patient's opinion and they've got a lot more experience dealing with insurance companies. Ask your doctor to write a letter on your behalf.
5) Did the hospital make a mistake?
The detailed hospital bill after a short hospital stay can run several pages. It's possible that the hospital made a mistake and added charges for items or procedures that you never got. Double-check the bill with the hospital billing office and often the result is that some items are checked off the bill.
6) Don't pay unless you have a say.
If you choose to see an out-of-network doctor, most insurance plans make it clear that you'll have to pay more. But if you never had a chance to give consent to receive care from an out-of-network doctor, you shouldn't have to pay the out-of-network cost. For example, if you go in for surgery and the hospital chooses an out-of-network anesthesiologist without your consent, you're not liable for the added cost.
7) Learn to talk like a nurse or a doctor.
The better you can explain that pain in your leg, the better your doctor can decide what tests are justified. Terms like, "persistent," "debilitating," and "sharp, lasting pain," go a long way to conveying to your doctor the severity of your situation. When you can explain your condition in the words that doctors use, it can more clearly communicate the extent of your problem and make it easier for the doctor to justify certain tests or a course of treatment. It can mean the difference between a doctor ordering the tests and them being covered and you asking for tests which wouldn't be covered.
8) The more you know, the more you'll get.
It might be a really boring read, but the better you know your health insurance plan, the more you know what you're entitled to receive and when an insurance company's denial is wrong.
9) Where you live, can determine what you get.
Some state's mandate that insurance companies cover certain procedures or a specific length of stay in a hospital. If you're claim is denied, check to see if there are any state mandates about the type of medical care you received.
For more help with insurance questions and resolving disputes with your insurance company, try one of these phone numbers.
Health Insurance and HMO Inquiries
Office of Consumer Health Insurance 877-527-9431
Medicare Beneficiaries & Caregivers Inquiries
Senior Health Insurance Program (SHIP) 800-548-9034
All Other Consumer & Healthcare Provider Inquiries
Consumer Assistance Hotline 866-445-5364
Consumer Affairs Division
Consumer Hotline 800-726-7390
Missouri Department of Insurance
General office number 573-751-2640