By Martine Brousse, a financial advisor on NerdWallet’s Ask an Advisor.
In the mysterious world of insurance appeals, final determinations are based on the merit of your grievance, your insurer's policy and your plan benefits. Following these tips may lead to better outcomes.
1. Know the Facts
Providers should be initiating the vast majority of appeals. They have the medical, coding, and technical knowledge to do so. If they refuse, or are unable to do so, you should, at a minimum, receive all relevant supportive documentation.
If a claim was rejected for billing errors (incorrect codes or diagnosis ID, for instance), filing an appeal is a waste of time as only a processed and paid claim can be appealed. Your doctor's billing person should resubmit corrected charges, or provide your insurer with any requested documentation.
If a charge is rejected as non-covered, not a benefit of the plan, not reimbursable under the insurance guidelines, experimental, off-label, not medically necessary or out of network, a talk with the office manager at your doctor’s office is in order. Was this information known to the office but not communicated? Was your policy checked before services were rendered? Is it a simple clerical error?
The answers will determine whether this is now appeal material, a financial issue between you and the provider, a third party responsibility (e.g., an incorrect diagnosis given to the lab whose claim was rejected) or your own error (e.g., you did not share your new card).
2. Who should appeal?
If the office is responsible, it should take immediate corrective steps, send records, or update information.
Billing mistakes made by secondary providers (labs, imaging centers) are common. Call them to verify your insurance ID or address. Many denials occur when invalid or non-payable diagnosis codes are forwarded with the order or prescription. Your doctor cannot be expected to know each payable diagnosis for every outside service. The order in your chart must be updated and completed before the appropriate biller can resubmit the charges with a payable code.
If information was withheld from you, either deliberately or by ignorance, insist the office appeal to your insurer with comprehensive explanations and detailed clinical justification from accepted sources. This process is best undertaken by both the patient and the provider and calls for payment due to “medical necessity.”
If you had no choice or option, and are being billed for services considered “out of network” or “non-covered.” do file an appeal, especially if the services were rendered under emergency conditions.
When in doubt, go ahead and file. You are within your rights to ask that your claims be reviewed, and your financial responsibility confirmed.
3. Be clear and precise
Why you are requesting the review of a charge? Asking your insurer to reprocess a claim just because they did not pay, or because you feel they did not pay enough, almost guarantees a denial of your request. Computers process claims, not people, and computers seldom make mistakes. Since an actual person will review your appeal letter, the exact reason(s) of your request should be clear.
Invoke your right to a “continuation of care” level of coverage if your doctor cancelled his or her contract in the middle of treatment and claims were paid “out of network.” Demand payment of non-contracted charges based on your emergency hospitalization. Demonstrate that “medical necessity” was met for a prescribed treatment or procedure by using your medical records, and supportive industry or Medicare guidelines. Ask for a reversal of a denial based on specific and unusual circumstances. Brand drug manufacturers offer ready-made sample letters to appeal coverage of their products.
4. Attach relevant documentation
Documentation is essential to any appeal. Zero or little documentation equals not much hope of success.
While I would not recommend sending truckloads of papers to the reviewer, ask the staff to provide the most appropriate clinical records to make your case. Ask them to direct you to related websites, significant studies, important links and online resources to add supportive documentation.
You may need to request records from a third party, usually the physician who ordered a specific lab, test or imaging service, in order to get medical justification and prove medical necessity. Remember to include the original order or prescription with your attachments.
Mail a copy of the appeal to the related provider, and ask for the financial responsibility to be shifted back to the insurance during this process. If the provider refuses, make small monthly payments ($5-$10) to keep your account current, show good faith and avoid collection action.