After trying to conceive on their own without success, a couple from outside Chicago wanted to use vitro fertilization, or IVF. Their insurance company refused to pay for the procedure, saying that IVF wasn’t medically necessary. The couple appealed the denial, only for the insurer to deny the claim again, this time arguing that the company had already paid for one round of IVF treatment, even though it hadn’t. Unsure of what to do next, the couple hired Gayle Byck to unravel the reasoning behind — and hopefully fight — their denied claim.
“I called and asked the insurer, ‘Could you tell me the date for the treatment?’” says Byck, who founded InTune Health Advocates, a private patient advocacy practice based in Deerfield, Illinois. “They kept me on hold for over an hour. They called me back the next day and agreed that my client had never had the procedure.”
With that, the couple’s insurer agreed to pay their IVF bill.
Appealing a denied insurance claim can be an aggravating, time-consuming process. To give yourself the best chance of winning an appeal, you’ll need to be persistent, know how your insurance plan works and be vigilant about noticing and correcting billing mistakes. With help from experts, we put together a primer on the appeals process.
Know your policy
Before you seek any kind of medical treatment, make an effort to understand what your insurance plan covers and what it doesn’t. It’s important to know if a provider is in-network, whether your plan requires you to meet a yearly deductible and what that amount is before your insurer will cover your care. Call the customer service number on your health insurance card and ask.
Once you know the ins and outs of your coverage, it will be easier to flag an unwarranted denial. “Remember, your insurance plan is a contract with your insurance company,” says Byck. “Really understand why they are denying it. Refer back to your policy so you can understand what your rights are.”
Craft your appeal
While patients often learn about claim denials after the fact, insurance companies may also deny coverage for a treatment beforehand, as with the Chicago couple’s IVF claim denial.
A claim might be denied for several reasons, says Caitlin Donovan, director of outreach and patient affairs for the National Patient Advocate Foundation, a group that helps people with chronic illness decipher denied health claims. Here are the most common scenarios:
1) A patient receives care in an inappropriate setting, such as by going to the ER for a sore throat.
2) A patient isn’t eligible for a medical benefit, i.e., their treatment isn’t deemed medically necessary. This tends to happen when a patient receives services for a diagnosis the physician failed to document. Say someone gets a headache, blacks out, hits their head and twists an ankle. A doctor orders CT scans and documents the reason, such as headache and head trauma. The physician also orders an X-ray for the twisted ankle but doesn’t document the reason. The insurer may approve the CT scan but deny the ankle X-ray as not medically necessary, since the supporting medical diagnoses didn’t mention or diagnose an ankle injury.
3) A patient doesn’t resolve a claim in time. Watch for deadlines: You have 180 days from the date of service to appeal a denial. The 180-day appeal window will be specified in an explanation of benefits form. Following any appointment or insured healthcare service (i.e., unless a patient self-pays for care), a patient will receive an EOB stating how much their insurance company paid for the treatment and how much they still owe. The deadline for an appeal is always based on the date of a treatment or medical visit — even when the EOB letter isn’t sent until weeks or months afterwards. When an insurance company denies a claim, the EOB will explain why and tell you how to file an appeal to counter the denial. “The EOB will tell you where to send any additional information, and it’s important to follow all the directions,” says Byck, adding that the insurance company will look for any reason to turn down an appeal.
Get your doctor on your side
“Once you have the exact reason the claim was denied, use that language to shape your own appeal,” Donovan says. “Think of it like a contract dispute and use facts, not emotions.”
If your insurer says that your treatment was not medically necessary, or that it’s considered experimental, go to your provider and ask them to help you prove its necessity, with documentation.
Always ask your provider to confirm the diagnostic code(s) they used for your diagnosis and treatment. On the off-chance they coded something incorrectly, they’ll need to resubmit the claim using the right code(s). If there were no coding mistakes, ask your provider to write a letter to your insurance company in support of your appeal. It’s helpful to have a physician endorse your appeal because it will be evaluated by the insurance company’s own healthcare providers, who are hired to review claims. “Sometimes a company’s provider is not a specialist in the area,” says Donovan. “I’ve heard patients say they need a certain neurological treatment, and the insurance provider reviewing it is an oncologist. It’s one more layer in why dealing with the healthcare system can be so frustrating.”
Do your own research
If you’re dealing with a denial from a private insurer, figure out if Medicare covers the treatment. (Donovan says a Google search should do the trick.) If the treatment is covered by Medicare, that means it’s considered the clinical “standard of care” and should be covered by most private insurers.
Another way to show that a treatment is considered medically necessary for a given diagnosis is to find medical journal articles that say the treatment is an accepted method of care. You can always ask your doctor’s office for help with this research. But if you want to do it on your own, stick to reputable, peer-reviewed journals (meaning those whose articles are evaluated by independent medical experts before publication). Two of the best known medical journals are The New England Journal of Medicine and JAMA (Journal of the American Medical Association). A comprehensive collection of peer-reviewed articles can be found on Pubmed, the National Institutes of Health’s database. You can also search for studies on Google Scholar.
“One way to determine the legitimacy of any journal, and thus the research inside, is to find the publication’s influence score,” Donovan says. (Influence score basically measures how often an article is cited in other reputable research.) “If an article is frequently cited, it should be considered a good source.”
If your appeal is denied, read your insurer’s explanation and try again. Then again, if necessary. “Our case managers are the best, and it still takes, on average, 22 calls for [an appeal to succeed],” Donovan says. “And we know it’s really frustrating for the patient to work through even one call.”
To appeal one of her own denials, Donovan talked to her physician’s office and learned that one of her claims had been coded incorrectly. She then spent time on the phone with her insurance company to make sure the code was fixed in its computer system. Then she waited: “I had the answer on the first day, and the claim took a year to resolve. It’s important to dot your I’s and cross your T’s.”
If a claim dispute drags on, you will likely start to receive bills from your provider requesting payment. In this situation, Donovan says, contact whoever is billing you and let them know you’re disputing the claim. If you do this, the billing company — which could be for a doctor’s office, a hospital or wherever you received treatment — should be willing to hold off looping in a collections agency, since they know you’re actively working with the insurance company to resolve payment. The last thing you want to deal with is the trouble of fighting an insurance claim while also battling a collection agency.
Don’t hesitate to push back
How often do medical bills contain errors, such as incorrect or incomplete codes, or wrong information about the patient or provider? Estimates vary widely; one 2017 report put the error rate between 30 percent and 90 percent. “People tend to be shy about pushing back on denials or challenging bills with errors, and they shouldn’t be,” says Donovan. “It’s important to get things right when medical issues and financial security overlap, especially if you are putting off an appointment or procedure over concern about how much it costs.”
Donovan recommends advocating for yourself as you would for a child: “It’s not unlikely that an insurance company is wrong. Obstacles will be thrown in your path. You have to have conviction.”
To beat an insurer at its own game, keep fighting. “Insurance companies are counting on attrition,” says Byck. “If you stick with it, your chance of success goes up.”