In my ideal future world, people will no longer have to deal with profit-hungry insurance companies. Yes, we’ll still have government bureaucracy but that’s a post for another day.
If you’ve been around long enough, you’ve probably had many dealings with insurance companies over benefits. I’ve heard horror stories of being denied needed services due to the pre-existing condition clause, which I hope is no longer an issue under the Affordable Care Act. Because I enjoyed company-sponsored plans, my family and I did not have to deal with the pre-existing clause issue. Our most common battle was over covered vs. non-covered services.
Denials can happen if you’re trying to get pre-approval for services or if you obtain a service thinking it was covered only to get a bill for the entire amount. Over the years, I’ve received many denial of services from insurance companies and I’ve gotten pretty good at fighting back.
In the beginning, I would call or write angry letters that got me nowhere. Luckily, I was able to find good advice online about how to fight insurance companies. Since then, I have won all challenges except for one case. That’s because 9 times out of 10, a denied service is actually covered. Insurance companies just don’t want to pay it.
I will break it down to easy steps and I guarantee you have a chance to win if you do this.
1) Don’t bother calling unless you’re checking to see if it could be a billing code error.
2) Get your hands on your plan’s Explanation of Coverage (EOC) booklet. This is a thick booklet with detailed explanations about coverage, term definitions, exclusions and more. This is your bible.
3) Go through the EOC and mark all clauses that back up your claim that the service is covered. In all but one of my cases, I was able to find supporting documentation in the EOB, because as I wrote a few paragraphs ago, insurance companies just don’t want to pay.
Original “Hate Mail” Postcard designed by Mr. Bingo.
4) In a letter, state your case in a calm, professional manner. When you cite something from the EOC booklet, include the page number in the body of your letter and write (see attachment). Include a copy of that page with your letter. If you have multiple attachments, refer to each by letter – attachment A, B, C etc.. – and write this letter on the corresponding documentation.
5) Tell them you’re requesting a 2nd review of this matter.
6) End by putting the burden of proof on them. Ex: “If you decide to deny my request, please inform me of the section of my plan description upon which you base your decision to deny my benefits. Please provide me with the names of the persons who have made the decision to deny my payment.”
7) Make copies of letter and supporting documents.
8) Send registered mail with someone signing to receive it. Make sure you’re sending it to the right department. All EOC booklets should include an address where you should send this type of request.
Under the Affordable Care Act, there is a standardized process for appealing claims. Read more here. I haven’t done this but I believe many of my tips would still apply.
Final Tip: It may take a while to get a response. This can be tricky if you owe money to a doctor or hospital. You can cc: your medical provider’s billing office in your letter or call to let them know that you’re addressing this bill. Writing is always better!
Good luck! Please share your experiences and helpful tips in the comments.
This is one in a series of tips/ideas to help you stay middle-class (HTSMC). Whether you consider yourself on the lower- or higher-end of the spectrum, you can probably find some useful tips to help you stay there and find save more for retirement even as wages stay stagnant.