NASHVILLE, Tenn. (WTVF/CONSUMER REPORTS) — Has this happened to you: Your doctor says you need a test, a treatment, or a medication, but your health insurance refuses to cover it. So what do you do?
According to a report from Kaiser Family Foundation, about 18% of in-network claims from people insured through an Affordable Care Act plan were denied in 2020.
You may think that if your insurance company won't pay for it, you'll need to find a way to pay for it yourself. But before you do, know that you have a guaranteed right to appeal the insurance company's decision — and it’s really not that hard to do.
Step one: Call your insurance company to make sure there wasn’t an error with your claim.
"Mistakes can and do happen at multiple points in the claim filing or pre-authorization process, and they are often relatively easy to fix, once you identify them," said Lisa Gill with Consumer Reports.
If it was not a mistake, ask to speak to the reviewer behind the decision and request an explanation. You’ll need this information for your next step — filing a formal appeal specifically stating that you disagree with the decision.
"You’re going to ask your doctor to help to write a letter that explains the necessity for the procedure and include as many supporting documents as possible — like your medical records and treatment studies and any communication with the insurance company," Gill said.
Doctors are used to this, so don’t be afraid to ask.
The next step might be the hardest: Waiting. It could take 30 days or longer for an answer, but if you need the denied treatment right away, make sure you request an expedited review.
"So if you get a letter that the insurer is still choosing to deny the claim — both Medicare and the private insurance are required by law to give you the reason in writing and tell you how to appeal the decision for review by an independent third party," Gill said.
If your claim was denied by Medicare, there are several additional actions you can take if your initial appeal is denied that could eventually lead to a hearing before a judge. If you get your insurance through your employer, your company's human resources department may be able to help.
