Welcome back! This blog provides financial resources and information for people living with cancer. In this post, I want to focus on dealing with denied insurance claims.
For this post, I am using the term “insurance claims” for all bills that your cancer treatment team submits to your health insurance company for payment. These bills are submitted after you receive medical services. If your health insurance company denies payment of a medical bill, it becomes a “denied insurance claim.” The patient is then responsible for payment.
Why are insurance claims denied?
Cancer treatment claims are denied for a variety of reasons, despite the amount of the bill. Information on the reason for a denied claim can be found on the explanation of benefits (EOB) that your insurance company mails to you. Usually there is a code next to the service provided. Sometimes this is easy to read, such as a duplicate bill received for the same service. Claims are often denied for incorrect billing codes, misspelled names, mistyped ID numbers, etc. More complex reasons for denials include services/medications that are not covered by your plan, prior authorization was not obtained, or service provider was out of network.
Don’t Delay Opening Mail! During cancer treatment, you may be tempted to let your unopened mail pile up until you feel better. Unfortunately, denied claims have a time limit for appeals. At the minimum, open all mail from your health insurance company and review all EOBs for payment information at least weekly. For ideas to keep organized, go to: Get Organized https://livingwithcancertakemyhand.com/2020/11/23/getting-organized-during-cancer-treatment/
How to appeal a denied claim:
Start by talking with your cancer treatment team. More than likely, your doctor’s office or treatment center has someone on staff who works directly with insurance claims and denials. If they do, let them handle the appeal. Often appeals are successful if the denial was a result of a clerical error.
It is difficult and possibly frustrating, but it is possible for you to submit an appeal yourself. If you have access to a computer, go to your health insurance company website. Search for “Claim denials.” Follow the steps to submit an appeal. If a phone call is easier, follow the steps below:
- Make a list of questions about your denied insurance claims.
- Have your health insurance policy and EOB nearby for reference.
- Contact the member services phone number on your insurance ID card. Anticipate a 30–40-minute phone call.
- Ask to talk with a claims representative.
- Once you have a claims representative on the phone:
- Write down their name and direct phone number/extension.
- Ask why your claim was denied. Take notes including date and time of call.
- Ask what the process is to appeal the denied insurance claim. Write it down.
- If they are using medical terms that you do not understand, tell them and ask them to explain what they mean.
- Ask what is needed to have your claim approved. It may be something as simple as asking your doctor’s office to fax an additional code or clinical note.
- Acknowledge that it’s possible that the requested services are being denied for a valid reason, such as an out of network provider or medications that are not FDA approved. As the service has already been received/performed, your cancer treatment team may be able to offer options for payment.
- Avoid drama. Depending on the reason for the denial, it is easy to get angry and raise the volume of your voice when speaking to the representative. This will not help your case. If you think you may not be able to remain calm during this call, ask a family member or trusted friend to make the call with you. The insurance company representative will ask to speak to you to obtain a verbal agreement that he/she can discuss your medical information with another person.
- Your next step usually includes submitting a letter to your insurance company.
- Be specific, factual, and detailed in the reason your claim should be paid.
- For letter templates, go to: Common reasons for a denial and examples of appeal letters | Washington state Office of the Insurance Commissioner
What if it is more complicated?
One of the most complicated reasons for denied insurance claims is a determination that the services received were not medically necessary. This can be frustrating when you are coping with a cancer diagnosis and treatment. Insurance companies require specific information within a limited timeframe to overturn a denial. This information is best given by your doctor during a “peer to peer” appeal. It has been my experience that this process can be effective, but also requires a significant time commitment.
If one or more internal appeal is unsuccessful, you can request an external review. This is a review of the claim by a neutral party. Depending on the amount of the unpaid claim, it may be worth your time and effort. The Kaiser Family Foundation reports an average of 45% of external reviews result in successful appeals.
If your insurance claim continues to be denied, you may need to contact a health or insurance claim ombudsman. This is a state appointed advocate that works with insurance denials. For state information, go to State Web Map (naic.org). Once you open your state’s insurance website, click on the consumer tab for details. Information on Medicare ombudsman services can be found at Medicare Beneficiary Ombudsman (MBO) | CMS
For More Information:
Health Insurance Claim Denied? How to Appeal the Denial (naic.org)
How do I file an appeal? | Medicare
How to appeal an insurance company decision | HealthCare.gov
I hope this information is helpful. If you would like to continue this conversation, please click on the Subscribe button at the top of the Blog page. I would love to hear your comments as well as resources that have worked for you. Please share this information with your family and friends.
Keeping you in my prayers,
Jackie
