How to Win Your Insurance Appeals: Essential Steps to Properly Challenge a Denial and Secure Your Coverage
In a 2023 Kaiser Family Foundation Survey, nearly 60% of US adults experienced problems with their health insurance, such as denied claims, provider network problems, and pre-authorization problems. So with the help of our Revenue Cycle Expert Barbara Zook, we put together a step by step guide of how to appeal your insurance company when your health insurance claim has been denied.
Nearly 60% of US Adults have dealt with a Health insurance claims denials or have experienced problems getting coverage with their preferred provider.
How to Successfully Appeal an Insurance Denial
If your health insurance claim is denied, or a medical service you need isn't covered, don't lose hope. You can and should challenge this decision. Below we’ve included a step-by-step guide to navigate the appeal process effectively:
Understand Your Health Insurance Policy: Start by thoroughly reviewing your insurance policy. It’s crucial to know exactly what your plan covers and what it doesn’t. This knowledge forms the basis of your appeal.
Clarify the Denial: Reach out to your insurance company to understand why they denied the claim. Request a detailed explanation and the specific policy terms they used to justify their decision. Specifically you should ask them about the insurance policy provision they relied on to make their decision. According to Barbara Zook, insurance denials are most often related to non covered services based on diagnosis that the physician may have incorrectly coded with the ordered service requisition. If this is the case, your physician’s billing office will need to correct and resubmit the diagnosis code to insurance.
Collect Evidence: Compile all relevant documents that support your case. This might include medical records, test results, prescriptions, and statements from your healthcare provider, demonstrating the necessity of the service or treatment.
Submit Your Appeal: File your appeal within the deadline specified by your insurance policy. Ensure your submission includes all required documents and a clear argument challenging the denial.
Get Expert Help: If the process seems daunting, consider seeking help. Organizations like Tricky Bills can assist you in framing your appeal correctly. You might also consult your HR department, state insurance regulators, or a healthcare lawyer for additional support.
Stay on Top of It: After submitting your appeal, keep in regular contact with your insurer to monitor progress. You will need to follow up with your insurance company to confirm they have received your appeal and are processing it in a timely manner. Record all communications, as this documentation can be crucial in pushing your appeal forward.
Appealing an insurance denial is not just about challenging a decision; it’s about advocating for your health and financial well-being and insuring you get the health benefits that you’re entitled to. Although it might be a lengthy process, persistence is key to obtaining the coverage you rightfully deserve. If you need additional assistance, consider reaching out to your HR Department, a healthcare attorney or Tricky Bills' experts who are ready to assist you through this journey.
