Wouldn't my doctor or hospital be more effective at appealing my denial?
Some hospitals and doctors are very proactive regarding appealing denials. Others set a minimum dollar amount and only appeal denials above that figure. Regardless of whether they plan to appeal or not, it is in your interest to appeal the denial, too, since the health insurance policy is in your name and you likely have ultimate responsibility for the charges. Further, some laws require insurance companies to give a more complete response to the policy holder than they give to a third-party medical provider. Insurance carriers often take more care when responding to policyholders.
I don’t think my insurance company will overturn the denial. Why waste my time?
You may be right. However some insurance regulations and even some independent review mandates requires the policy holder to first file an internal appeal with the insurance carrier. Therefore, this is a prerequisite to getting an outside agency or even, in some instances, prevailing in court. When understood in this context, it it not a waste of time but a bureaucratic necessity.
However if you do not prevail, you have other options. Currently forty-two states and the District of Columbia have independent review boards. Further, many insurance policies require you to file appeals before litigation is pursued. Once these appeals are conducted, you are free to pursue the matter in court.
What types of disputes are eligible for appeal?
Generally, any denial of benefits can be appealed. Confusion sometimes results from the fact that state independent review boards may impose restrictions on the type of provider, the nature of the procedure, or the dollar value of a disputed claim that they will review. However, any denial of benefits can be appealed directly to the health insurance carrier.
Are there any time limits for filing an appeal?
Yes. Your policy may very well set a limit for the time frame for filing appeals. Further, some states’ independent review boards require an appeal be filed within a certain period of time after a claim is denied. Finally, the Employer Retirement Income Security Act which applies to most insurance benefits obtained through a place of employment requires claimants to file appeals within 180 days.
Will a state independent review board be any more sympathetic to my claim than the insurance company?
Often state independent reviews are conducted by physicians specializing in the area of medicine under dispute. Therefore, they may be much more familiar with the treatment than the insurance company medical director which may be trained in an entirely different specialty. Further, they may be more familiar with the most recent information regarding new or experimental procedures because they more frequently make decisions regarding these types of treatment.
Is filing an appeal complicated? Do I need an attorney?
No and no. Just like your insurance contract, the appeal requirements are supposed to be written to be easily understood by people who have never been to law school. However, should you decide to retain an attorney to better protect your interests, we include in our Appeals Guide For Patients information which should be helpful in selecting and negotiating representation.
How long does the appeals process take?
Our Appeals Guide For Patients gives a description of many of the state mandates which govern how long insurance carriers can take to review internal appeals. ERISA governed plans must make a decision within 72 hours for urgent care claims to 60 days for post service denials. Independent reviews generally take 60 days but can be expedited for pretreatment reviews of an urgent nature.
What are my chances of success?
It is impossible to judge your specific chance for success. However, pursuing an appeal will give you a much better understanding of your insurance contract and assure you that not just one reviewer, but several, reviewed the merits of your claim. It seems like a step any one with a denied claims should want to take.