10 Tips For Overturning Denied Health Insurance Claims

Deborah Gray Health Guide
  • As I said in an earlier blog, knowing how to handle your health insurer is one way to be a smart patient. Knowing how to handle denials is obviously a big part of that, since it's the one time most of us have a problem with our health insurance.

    You probably will see denials more often for courses of talk therapy than anything else. Therapy is the most expensive form of treatment. But your insurer may also deny your doctor's request for brand name as opposed to generic medication.

    Don't be discouraged if you receive a denial for a type of treatment, and don't assume the decision is set in stone. Sometimes all your insurer needs to approve the request is a little more information. Sometimes you and your doctor need to explain why your situation is an exception to their policy.

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    Here are some ways to improve your chances of overturning a denial:

    1. Read your benefit plan from cover to cover.
    This is something that most of us don't do. I know that I do it reluctantly, since more often than not it contains unpleasant surprises. But you need to know where you stand in terms of what treatment is available to you (and what is supposedly not).

    2. Know what is expected of you.
    In general, your part of the bargain usually involves getting pre-certification for procedures and filing paperwork on time. But it's very important to know exactly what you need to do to hold up your end of the process.

    3. Get to know your insurer's appeals process.
    Among other things, you need to know how long you have to appeal. There usually is a deadline of between 30 and 45 days to file your appeal. Find out if there is a form to fill out, or if you simply send a letter.

    4. Enlist your doctor's help.
    Talk to your doctor about any denials and ask for help in fighting them. He or she will also have someone in their practice who's responsible for dealing with health insurers. He or she should have a lot of hints and tricks to pass on.

    5. Work your way up the chain of command.
    The customer service rep you get on your first phone call doesn't have the power to make an exception in your case if it goes against standard policy. Politely acknowledge this and ask to be referred to their supervisor or someone else who might be able to.

    6. Be persistent.
    This is a major component in succeeding to overturn a denial. Don't get frustrated or discouraged. Recognize that chances are good that you won't succeed right off the bat. Just keep trying.

    7. Be polite.
    The old saying about getting more flies with honey than vinegar is definitely true in this case. The nicer you are, the more the customer service people will want to help you. If you take your frustrations out on them, they will tune you out.

    8. Document all communications.
    For all phone calls, you should document the date, time, name and title of the person you spoke to and summarize the conversation. If the representative is supposed to get back to you with an answer, make sure you get the person's direct extension, if possible.

    9. Follow up.
    Set yourself a schedule after each call for following up, like three business days.


  • 10. Be organized.

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    Keep all your notes and papers in one folder so that you have it all at your fingertips.

    While there is no guarantee that you'll succeed in overturning an appeal, utilizing these tips improves your chances greatly. Good luck!

Published On: January 23, 2007