Make Your Health Insurer Pay

Claims denied? Here's what to do.

by Meryl Davids Landau
Photograph: Photo: Plamen Petkov

Try this If your health won’t suffer, it’s easiest just to follow the required steps. Already tried the other meds? Send proof to your insurer in the form of old prescription labels or other documentation. Know that some insurers cover certain drugs only if you meet a clinical threshold. For example, they may limit the injection drug Reclast (which costs about $1,000 for a yearly dose) to women whose bone scans document osteoporosis, not its precursor, osteopenia. Mary Fujii, reimbursement manager at ­Hematology-Oncology of Knoxville, in Tennessee, says she regularly sees women come for the drug only to learn that their insurers don’t consider them candidates. “If you’re going to a specialist for a specific therapy, send him your records for evaluation beforehand,” Fujii advises. Also check if your insurer has special requirements for new, and therefore probably pricey, drugs.

If all else fails If you urgently need the newest Rx now, ask your doctor to arrange a “peer to peer” phone review, in which he’ll talk with an MD at the insurance company. (And be aware that if you do get a yes, you’ll be paying more out of pocket: Expensive new “fourth tier” medications can carry copays of about 25 percent.)
 Your insurance company denies coverage of a cutting-edge procedure because it is experimental
Say your gynecologist wants to use robotic surgery to repair your prolapsed bladder. This procedure, newer than traditional surgery, permits a much smaller incision and faster post-op healing—yet your insurer may insist on the old-school operation on the grounds that while the patient’s experience is better with the robotic surgery, the medical outcome is the same.

Try this Ask your doctor to make his case by including in his written precertification request published journal articles and practice guidelines about the treatment. You’ll also improve your odds of succeeding if the physician can cite instances in which the procedure has saved insurers money. “After years of refusing payment for robotic surgery, some companies are finally giving it the green light because it substantially cuts the hospital stay,” Marshall says.

If all else fails It’s heartbreaking to think you may have to endure more pain and a longer recovery time than necessary. But if your doctor can’t convince your insurer, you may have to settle for an older (and fully paid for) procedure. A riskier option is to look for treatments that are usually free because they’re cutting edge: those performed in clinical trials conducted before FDA approval. Most often, the researchers pay for the experimental therapy or drug, which may be promising but is not yet officially deemed safe and effective. Find trials at clinicaltrials.gov.

You want to see that top out-of-network specialist—but your insurer will pay only a small fraction of the physician’s fee It’s most cost effective for you to see doctors in your insurer’s network, all of whom have usually agreed to accept a reduced fee. Out-of-network MDs can charge as much as they like, but your insurer will cover only a small amount, and you’ll be billed for the rest.

Try this You may be able to justify to your carrier that a particular specialist is crucial to your care. “If there are no qualified in-network experts in your geographical area, you could be in a strong position to get the fee covered,” Fujii says. You’ll have less success if you prefer that physician simply because of her top reputation.

If all else fails Ask the provider if she’ll reduce your fee. “It’s not uncommon for out-of-network doctors to lop off a percentage from what you owe,” says Cindy J. Holtzman, a medical advocate in Marietta, Georgia. And if you have a flexible spending account (FSA), in which your employer sets aside pretax dollars for you to spend on health care expenses that aren’t reimbursed by your insurance company, this is a great time to use that money. If not, here’s a good reason to sign up for an account next year.

Your policy doesn’t cover alternative medicine

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