Receiving a medical bill for a service your health insurance should have covered can evoke feelings of “rage, frustration, or exhaustion”. This experience is common, with many individuals facing unexpected charges, even for supposedly free preventive care.
KFF Health News reporter Jackie Fortier, who covers the topic extensively for the “Health Care Helpline” project, conducted an interview for NPR radio and offered crucial advice on how to appeal these denials and fight for the coverage you are entitled to. She emphasized that while the process can be “hard” and “time consuming,” appeals often succeed, and it’s essential “not to take the first no as the final answer”.
Preventive care, such as annual physicals, vaccines, and cancer screenings like mammograms and colonoscopies, is generally required to be covered at no out-of-pocket cost under the Affordable Care Act. However, denials still occur, sometimes due to “billing issues or coding mistakes or how a visit…is classified”. Factors like age and health history can also influence whether a specific test is considered preventive and therefore covered. Even a routine wellness visit can become a “problem visit” if a health issue is discussed, potentially leading to additional charges like co-payments or deductible fees.
What to Do When Your Health Insurance Denies Coverage?
When faced with a health insurance denial, Fortier outlined a multi-step approach, stressing the importance of persistence and meticulous documentation.
- Understand the Reason for Denial: Don’t panic, but immediately read the rejection document carefully to understand why the claim was denied. The explanation of benefits (EOB) is not a bill but lists costs and what the insurer will pay. Look for phrases like “not medically necessary” or “not a covered benefit”. If the reason is unclear, call the customer service number on the back of your insurance card, be polite, ask questions, and write down details like who you spoke to and what they said. Getting information in writing is even better.
- Initiate an Internal Appeal: Once you know the reason, file an internal appeal with your insurance company. This process doesn’t require a lawyer; you’re simply asking the insurer to reconsider. Locate your insurance policy, often called the “summary plan description,” to understand what’s covered and the appeal procedures. You typically have up to 180 days to file.
- Handle Medical Bills During Appeal: If you receive a bill from the medical provider or hospital while your appeal is pending, contact their billing department immediately. Inform them you are in the appeals process. If you are appealing, they generally “can’t collect from you”. Do not pay the bill or put it on a credit card, as this can convert medical debt into credit card debt, making you lose certain protections and incur interest.
- Build Your Case with Documentation: Appeals are about “documentation, not emotion”.
- Fill out the appeal form, usually found on your insurer’s website or explanation of benefits.
- Write a concise, factual letter explaining why you disagree with the rejection.
- Include relevant medical records or test results.
- If it’s a preventive service, include a copy of the federal regulations that mandate coverage.
- Crucially, obtain a letter from your doctor explaining why the treatment is “medically necessary and preventive” for you, with their medical reasoning. This carries significant weight.
- Submit and Verify Receipt: Upload your appeal documents to the insurer’s online portal or send them via certified mail to have proof of delivery. Always keep copies of everything for your records.
- Monitor Your Credit: Keep an eye on your credit report to ensure the bill doesn’t appear as unpaid or delinquent. If your appeal is successful, get written confirmation from the insurance company and retain it for approximately a year.
- Request an External Medical Review: If your internal appeal is denied (even twice), do not give up. You can request an external medical review. This involves an “independent health professional” who will review your case. Their decision is “final,” “unbiased,” “medically based,” and “legally binding” for your insurance company. Many states offer free assistance from agencies like the State Department of Insurance or Attorney General’s office to help navigate this process. The insurance company is legally required to inform you how to request this review. This step has a high success rate, with one California department reporting 72% of members winning their cases. Standard reviews can take up to 45 days, but urgent cases can be expedited in seven days or less.
- Explore Options if All Appeals Fail: Even if the external review doesn’t side with you, there are still avenues to explore:
- Negotiate the bill with the provider: Contact the doctor’s office or hospital billing department and ask them to lower the bill. They may accept a “settlement amount” or offer a discount for cash. If an agreement is reached, get the negotiated amount in writing.
- Apply for financial assistance: Many hospitals are non-profit and are required to offer financial assistance based on income.
- Set up a payment plan: If negotiating isn’t an option, arrange an interest-free payment plan with no late fees with the billing office.
- Involve your Human Resources (HR) department: If your insurance is employer-sponsored, contact HR. They might be able to advocate on your behalf, identify trends in denials affecting other employees, and even prompt changes at the company level with the insurer. Anna Deutsche’s experience with her son’s hearing tests demonstrated how HR intervention can lead to positive outcomes.
Of course an alternative to dealing with constant headaches from health insurance companies is to look for alternatives such as healthshare schemes which, while not regulated as insurance, can offer a much more straightforward and reliable form of coverage, especially for healthy Americans.