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Q: Wouldn’t my doctor or
hospital be more effective at appealing my denial.
A: 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 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. Therefore, often, insurance
carriers take more care when responding to policyholders.
Q: I don’t think my
insurance company will overturn the denial. Why waste my time?
A: 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 beauracratic 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.
Q:
What types of disputes are eligible for appeal?
A: 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.
Q: Are there any time limits for filing an appeal?
A: 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.
Q:
Will a state independent review board be any more sympathetic to
my claim than the insurance company?
A: 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.
Q: Is
filing an appeal complicated? Do I need an attorney?
A: 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 Easy Appeals Guide information
which should be helpful in selecting and negotiating
representation.
Q: How
long does the appeals process take?
A: Our Easy Appeal Guide 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.
Q:
What are my chances of success?
A: 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.
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