Make Your Health Insurer Pay

Claims denied? Here's what to do.

by Meryl Davids Landau
Photograph: Photo: Plamen Petkov

At each of her past few annual mammograms, Melissa Cogliati was told her breast cysts make it hard for the radiologist to interpret the film. Her gynecologist always insisted she schedule a follow-up ultrasound, which her insurance covered in full. So last year, with her doctor’s OK, Cogliati booked the two screening tests for the same day. “It made sense for me to get everything done while I was already there,” the Louisburg, North Carolina, resident recalls, but her insurer didn’t agree. For reasons that are still unclear, it paid for one procedure but not both, and Cogliati got stuck with a bill for $369.

You may think the national health care reform act has halted these seemingly arbitrary insurer-payment decisions (and if you think claim denial is rare, consider this: Up to a third of claims submitted for the first time are turned down). But while the new law does remove important obstacles to acquiring and keeping coverage, its changes unfold on a timetable: Right now many of its fixes apply only to people with new policies, and the rest of us must wait until 2014. (You have a “new policy” if you join a plan after changing jobs or carriers or if your current policy undergoes significant changes, such as in the benefits available or the size of the deductible.) Also, the legislation doesn’t end many of the more common claim-denying practices of insurers.

To help you get the coverage you’re entitled to, More has come up with this guide to resolving some familiar insurance snafus.
 Your insurer says the treatment your doctor has prescribed is not medically necessary
Doctors and insurance companies are in a ferocious tug-of-war over who gets to define “necessary” treatments. Often called into question: treatments such as electric nerve stimulation for some overactive bladder problems.

Try this Sometimes the insurer rejects a claim because the treatment was improperly coded. If you’re really surprised by a turndown, ask your doctor’s office to phone your insurer and check the codes, says Donna Marshall, former business manager at the National Center for Advanced Pelvic Surgery at Washington Hospital Center in D.C. Always prevent after-the-fact rejection shock by getting the procedure precertified, if that’s required, or by calling the customer service number on the back of your insurance card before you schedule a treatment.

If all else fails If your doctor believes that you really need the treatment, formally appeal the decision (see “Dealing with Denial,” above). Your denial letter will tell you where to send the appeal. If your case is particularly outrageous, send a copy of your appeal letter to your state’s attorney general and insurance commissioner, suggests Mark Rukavina, executive director of the Access Project, a health care research and advocacy organization in Boston. Follow up with phone calls if you don’t get the help you seek.
 You want a new kind of drug, but the insurance company says no
Insurers typically encourage patients, through high copays, to try cheaper medications before moving up to newer, pricier options. “It’s known as step therapy, and the insurance company will authorize only the least expensive alternatives prior to going to the more pricey options,” says Omaha dermatologist Joel Schlessinger, former president of the American Society of Cosmetic Dermatology and Aesthetic Surgery. This is probably your health insurer’s position on the new diabetes drug Byetta, the once-a-year osteoporosis treatment Reclast and the IV-administered arthritis medication Orencia.

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