“Attitude is more important than facts.”
This quote is from noted psychiatrist Karl Menninger who understood the vast importance about attacking a difficult situation with a strong mindset.
In appealing denied insurance claims, you need to have the mindset that it is the insurance carrier’s burden to prove that the claim has been processed correctly and that any ambiguities in the coverage terms were construed in the insured’s favor. A strong mindset will also give you the perseverance necessary to continuing to appeal a claim the insurer strongly defends.
Attitude is more important that facts, because the right attitude will help you persuade the insurance carrier to look at the facts differently.
Many claims are overturned after a single appeal letter. However, you want to persist with filing appeals until you get a satisfactory answer. When you do not receive an adequate response to your appeal from the appeals committee, it is imperative that you continue to appeal.
Persistence is often the key to overturning a denied claim. Many carriers overturn as many appeals during the second and third appeals as on the first appeal. It is crucial to keep the appeal active, even after the initial denial.
In fact, statistics released from major insurance carriers indicate that about 25 percent of appeals are overturned on the first appeal and another 25 percent are overturned on the second appeal.
If you believe payment is indicated by the policy terms, continue to appeal the claim. See below for information on keeping your appeal alive.
Don”t Settle For “Denial Upheld”
Appealing denied insurance claims requires perseverance. You may find that your carefully researched and strongly worded appeal is not being reviewed adequately by the claims department. In such instances, you can redirect your appeal to someone in a better position to review and respond to the information you have cited. Consider sending your appeal to one of the following:
Carrier Legal Counsel – If you have cited regulatory information, you can request a review and written response from the legal department.
Carrier President – If your appeal involves a possible breach of claim processing procedures, ask the President or other senior management official to respond.
Department of Labor – If the insurance is self-funded, file a complaint with the Department of Labor. Send a copy of the complaint to the insurer.
Employer – The employer will have an appeals committee if the group is self-insured.
Department of Insurance – File a formal complaint with your state’s Department of Insurance if you are unable to get a satisfactory response. Send a copy of the complaint to the insurer.
State Medical Association – Many medical associations now have a complaint review process and will assist you with resolving denied insurance claims.
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