Note: This is a rough transcript of episode 16 of Health Savings News and has been lightly edited for clarity. Copy may not be in its final form.
Hello and welcome to Health Savings News, the podcast about healthcare costs in America, and how to save money on the often expensive care all kinds of people need. I’m your host, Evan O’Connor, joined by retired doctors Rich Sagall and Mike Woods. How are you doing today, guys?
Good, and you?
Doing all right.
Good. Except for the bleak, rainy day, but…
<Laugh> it’s New England. Wait a minute.
It’s true. It’s the season for it.
Each episode we discuss healthcare costs in America, offer tips for saving money, and relevant news that affects and reflects the expensive landscape of healthcare in America. This week’s topic is how to appeal after being denied insurance coverage for a needed healthcare service. This can happen after a procedure is done leaving patients nominally responsible for paying the bill, or by rejecting prior authorization leaving patients potentially unable to afford a needed healthcare service. The process to appeal rejections is often deliberately laborious to dissuade patients from trying altogether, especially when they’re either recovering from a procedure or actively in need of healthcare. Today we’re going to give tips on how to negotiate the barriers of appealing to health insurance.
Why don’t we start off with the definition of an appeal. According to the government, an appeal is a request for your health insurance company or the health insurance marketplace to review a decision that denies a benefit or payment. You can ask your insurance company for reconsideration of its decision. Insurers have to tell you why they’ve denied your claim or ended your coverage.
Yeah, so what’s a denial? Well, a denial means one of two things. It means that the health insurance company has decided that a medical service or treatment will not be covered based on the terms of their policy. Denials can come for other reasons, most of which involve human error. Once you receive a denial, the insurance company has 15 days to notify you of the explanation as to why they gave the denial. And if it’s a prior authorization request, they must have it to you in 15 days. Or if it’s a post-service denial or for services you’ve already received, they must send it out within 30 days. The exception is when the service is an emergency care case and they need to get back to you within 72 hours. There are many reasons why you get denial, and as I said, probably the most common is human error when filling out a request, a prior approval, or in putting together a medical bill, which is usually due either missing information, using the wrong paperwork or form in proper coding, which is a very complex topic that that would take days to cover, an inaccurate bill or using the wrong procedure when applying for prior approval. Occasionally you’ll have a payment denied because you haven’t reached your deductible yet and someone had submitted the bill anyway, or you’ve maxed out your coverage limits in your health plan. For instance, most people have a limited number of physical therapy visits they’re allowed in a year, and if you exceed that number, you’ll start being billed for it.
The least common cause of a denial is for medical reasons. So when the terms of your policy and the nature of your medical care require either like a non-formulary medication, an unapproved treatment or test, or an out of network referrals, when it usually happens. And again, it usually happens when the insurance reviewer who is actually usually a physician does not agree with your healthcare providers about your need for that particular medical care. Sometimes it’s because you need to try something else because that’s the terms of your insurance policy, like a formulary drug, an in-network provider, or a standard testing for that case. However, it’s even more likely to get a denial if you forget to do any of these things like submit a prior approval, attempt to get an exemption for something, or don’t follow the correct procedures. Occasionally the insurance company isn’t disagreeing with the care necessarily, but where you actually got the care. For instance, some people will enter the hospital after a procedure and stay the night, but be there less than 24 hours. The hospital may have billed it as an inpatient cost, however, less than 24 hours is actually an observation stay and is much less expensive and the insurance company might pick up on that and only pay the observation coverage. Sometimes if you visit an emergency room and it was not appropriate, they may charge you a higher copay because it should have been done in a less expensive setting, such as outpatient clinic.
Very common reason why you get denials is you change insurance policies and you know, you really have no choice but to stay on the medications that are working or see the people that are taking care of you properly. But what happens when they’re not allowed by your new policy, the the company can then turn around and deny your previous care or providers just because you change to insurance policy that doesn’t have those features in it. And finally, if you have experimental or cosmetic or investigational procedures, it is a frequent reason for a denial. Of those three the one that’s almost never going to be approved is a cosmetic procedure. The experimental and investigational ones have a chance of being approved if they are the only medical care available for you. Any comments, Rich?
Well, I can give a personal example of this. I changed health insurance companies while I was in the middle of evaluating a certain problem. The person I was seeing originally was 15 minutes away and they wanted me to switch providers to one who was an hour away. I explained the difference and the distance that they wanted me to travel and said that was unreasonable. And surprisingly enough, they agreed. I was able to finish the workup and procedures with the non-covered or non participating physician.
So now that we know all about denials, I mean, are there ways to avoid this happening, the denials or the need for appeals?
Well, as you mentioned, one time this happens is when you’re finding a new insurance or being covered by a new insurance policy. And I would suggest before you get the new coverage, you look at the medications, providers, specialists, and the ancillary services you may be using and make sure they’re covered. Or if they’re not covered, they would provide equal coverage with an in-network provider.
Yeah, and the same is true for all the other things associated with your insurance, like physical therapist, imaging centers, formularies, and things like that.
Now, sometimes a covered drug may be able to be substituted for one that’s not uncovered, but that’s something you should discuss with your physician. And if it’s not, you need to have a good reason why you want the drug you are on and not one that’s similar and in the formulary.
Yeah, having said that, rich, I think one of the, the issues is that a lot of people when they get a new insurance policy really don’t have the choice or the ability to pick and choose the formulary and/or network that their insurance will cover. So in a lot of cases, it will just come down to trying to get your healthcare provider to convince your new insurance company that you really should stick with the things that have been working for you.
Right. And we’ll talk about that in more detail later on.
Now, once you have that insurance, there’s really significant number of ways that you can try to avoid denials, but that mainly involves being fully aware of every little detail of your insurance policy. Know that a formulary exists, it’s not really up to you to keep track of what drugs are on the formulary, but it’s really up to you to tell your provider that he should stick within the formulary. Most medical records in this day and age have individual formularies of your insurance company that they have access to that they can look at before they put the prescription. Tim is true of networks. Make sure you know what your network is and that your provider stays within it. Know your limits. You know, most insurance policies only allow one checkup per year. They limit follow ups for specialist visits or even the number of inpatient days that you can be in the hospital before you start having to pay fully out of pocket. Know what your deductibles are. Occasionally, again, you’ll get a bill rejected because you haven’t reached your deductible yet. The Affordable Care Act protects a lot of your healthcare and sometimes mandates that it be done free. So there are any number of screenings that are mandated by the Affordable Care Act that you really should not be charged for.
One of the things you said I disagree with, in the physicians know what drugs are covered on by which insurance policies. Private practitioners who may be dealing with patients with multiple different insurers have no way of knowing which drugs are covered. It’s just too complex.
Yeah, I actually wasn’t saying it quite that way. I’m saying that most physicians with electronic health records can access your insurance’s formulary from their computer. They just have to think to do it or take the time to do it. For those who don’t have the electronic health record or access to those things, yeah, it is a very complex and difficult process that may involve just you going online to look at the terms of your insurance policies and see if you can find the specific formulary for your policy and advise your physician as to what the medications that you can use are.
Often you can consult with a pharmacist because they would know and have easy access to which drugs are covered and which are not, and they may be able to suggest to your provider a similar drug that is covered.
Yep, I agree that’s probably an easier route than going to your primary care and doing your own research.
One of the final things is that I have a, you know, is a specific example for me. For example, I’m of the age that I, you know, I’m a high risk for shingles and there’s now a vaccine available for it called Shingrix. I’ve asked to get it at my physician’s office, but he tells me that my insurance will not pay for me to have it in his office. However, if I go to my nearest CVS, I can get it for free. So just making sure that you check about those things. Same thing is true of flu shots. In some cases you can get a flu shot free at the pharmacy when you might not otherwise be able to get it at your primary care’s office.
Local health departments can also do free vaccine clinics.
Exactly, yeah. In my area it’s mostly sponsored by the pharmacies. So you contact them rather than the health departments, but that’s a good idea as well. The other final thing is just really pay attention to the paperwork. It’s terribly important to get it right to get the thing in under the deadline and strictly to adhere to all the rules in your medical insurance. Now let’s move on to appeals. Now that we know about denials and how to avoid them if it comes up, the important thing to remember is you are guaranteed by the Affordable Care Act the right to formally appeal any denial from your insurance provider. And you are even allowed to appeal to an outside agency if you don’t get any satisfaction from your own insurance company. The ACA, the Affordable Care Act also has mandated a minimal standard about the appeals as far as what the effort they need to put into it, the details they need to review. Some states even have higher standards that you need to check on. And the final thing is each insurance company does have their own process. So when you need to do an appeal, you really need to start with your own insurance company and consult a letter of denial to see the details that you need to do before starting your appeal. So in most cases I said an appeal really isn’t needed. You just need to go back and get the paperwork right. You know, get the right coding, the right bill, the right information, the right form, et cetera, et cetera. Occasionally you get a denial for lack of prior authorization. You may be able to avoid an appeal by checking with your insurance company if you can file the paperwork after the fact. And like you said, in some cases you really don’t have any choice but to remain in the terms of your healthcare insurance and use the formulary treatment, or the network designated by your insurance before you can move on to an appeal or in potentially new medications and providers. Unless of course your provider thinks this is gonna be harmful if you wait too long and then you should begin the appeal process right away.
So there are reasons to appeal if you’re denied after your visit, if it was based on billing errors, inappropriate diagnosis, incorrect services provided, the benefits are indeed offered under your healthcare plan even though you were denied, or they were clerical errors. Sometimes the insurance company is not aware that the situation that you had was an emergency and you really had no option for prior approval. You just needed to get care. And finally, the part that most likely is what you will run into problems with disagreements among primary care and insurance companies are benefits that aren’t offered or excluded under your health plan, yhe provider or the facility isn’t in your network, the medication is non formula or too expensive and nothing is comparable, your care is doing medically and necessary but you really can provide evidence that it is, or if the treatment is experimental or investigation, but again, it’s the only option available for you. Occasionally you may be denied payment because your medical problem began before you join the plan. Now you’re saying the Affordable Care Act specifically prevented insurance companies from denying you health insurance based on a preexisting condition. While this is true, it really does not prevent them from limiting the amount of service or care you can receive for that condition. Occasionally you might get a denial because the insurance company decides you’re no longer eligible or enrolled in the insurance for whatever reason, or they claim that you gave false information or incomplete information on your application and they’re revoking or canceling your coverage back to the date when you enrolled.
Why don’t we move on and talk about how to appeal? I want to mention one other thing. At least with Medicare, I get a monthly statement of any services that were provided, prescriptions that were filled, or any other payments that they made. Although it seems to be a pain, it is worth checking that over to make sure that someone isn’t making mistakes and charging you for things that you shouldn’t be charged for.
Having mentioned Medicaid and Medicare at this point, I just want to let everybody know that the appeal process for Medicare and Medicaid is entirely different than what we’re describing today. And you will need to contact Medicare or Medicaid to find out what their appeal process is.
A few simple basic rules when you’re going to be doing an appeal. One is keep calm. Getting mad, yelling and screaming at people does no good except raising your blood pressure. You want to remember that the staff people you may be talking to at the insurance company just doing their job, it’s not personal with you. They’re just doing what they should be doing. They also have limited authority. They can only authorize certain things and you need to recognize that I’ve found it best. If you sympathize with the staff rather than getting mad at them, you get a lot farther. And most also important is don’t make threats you can’t keep.
So what do you do when you get that denial letter? Well, the first reason is obviously is to read over the letter very carefully. Identify the reasons for the denial and decide if you think an appeal is worthwhile based on the reasons for denial. That will involve you going back and looking at all the details of your policy that related to the denial and you trying to determine again, why they did it beyond what they actually stated in the letter. So if it’s one of those situations where it was just human error, you just correct any errors on the documentation and resubmit it and in most cases that’ll be all that you will need to do. However, if you still get denied, there are actually three ways to approach a denial in order of starting with a letter of appeal with information from you and your healthcare provider making a case for why the denial is inappropriate. Most denials are resolved at this level, but if not, there is now formal levels of appeal. A level one appeal involves reviewers within your insurance company that weren’t involved in the initial decision. And a level two appeal involves external reviewers. Now the important thing to remember, and Rich has already talked about this, appeals will usually be won and lost on details. Such as the cause of the denial, the amount of preparation you and your primary care provider put into the denial letter and how well you and your healthcare provider can make your case. So don’t go it alone, always get your healthcare provider involved right at the beginning of the process. Do all the research you can about the details of your policy, your medical condition, including the diagnosis and treatment. Because remember that even though it’s a physician reviewing your case at the insurance company, there’s no guarantee that he’s kept up with up to date standard practices. So it’s always worth learning that information on your own so that you can present that to the insurance company.
I would disagree with one thing that Mike said. It’s not a major point, but the first thing you should do if you’re considering an appeal is get a notebook so you can keep a diary of everything you’ve done. You may be the only one that’s gonna keep track of all the different steps that are taken. Along the same lines, you want to keep the originals of every document you create or your sent so you have those as proof if you, if it ever goes that far. So in the diary you should write all calls, correspondence, et cetera. You want to have the date and time you make the call. It’s very important to get the name of the person you speak to, their title, their phone number, et cetera. So you have some proof that it happened and you want to summarize what transpired. You want to keep it objective as opposed to subjective. Try to list the facts. You want to write down any promises they may have made, any requests you make for documentation, request references perhaps, and you want to demand follow up dates when they’re gonna get back to you. Don’t say we’ll get back in once we do our research. Get a date so you have something to go by.
First step as I talked about is the appeal letter, and Rich is the best to speak for this because he actually has personal experience in this area.
I have personal and also professional. When you write an appeal letter, you want to try to get all the information you need into that letter. So you want to get an email address to send it and if you’re really concerned, send it all a copy through the postal service with return receipt requested so you have proof they received the letter. You want to be concise, non accusatory and calm. You don’t want to sound paranoid about this, you just need to state the fact you want to ensure you include all the information that they might need. Your name, your address, your contact information and phone number and email address, the type of policy, your member number. If someone is helping you write it or is writing it for you, their name and their relationship. Next, you want to do a brief history of the problem. So if it’s headaches, for example, you may want to start off when you had migraines, when they began, the various different types of treatments you had over the years. If you can remember whether they worked or didn’t work, any other approaches besides medication, what you’re taking, any other additional diagnoses. I think it’s important to make it personal and talk about how the diagnosis is impacted on your lifestyle. For example, if someone has enough migraines where they couldn’t hold down a job, I think that’s very useful information to include in the letter. And have you had any success with medication or treatment? Hopefully you’ve had some success with the medication and it’s just a matter of getting it covered. So that’s the basics for the letter. In terms of you do want to, as Mike mentioned, contact your healthcare provider provider, see if they will give you some supporting documentation in terms of what’s been going on. Don’t include stacks and stacks of medical records. Just a summary will suffice. You want to include in this letter what you want and a brief summary. You should send a copy to your primary care provider, a specialist if you’re seeing one, and anyone else who’s involved with your care.
Yeah, as I mentioned before, sometimes physicians viewing it aren’t up to the current information on treatment protocols. You may also find that a person who is reviewing your case at the insurance company isn’t truly aware of all the details of your policy. So you may look through the section of your policy called evidence of coverage and you might find information that will support your appeal because what they say is not covered under your insurance policy actually is.
The initial appeal is probably done by a staff person with very little medical knowledge and their just following the decision tree that the insurance company has. In some companies you may be able to talk to the physician who denied this. Probably that won’t happen in most cases, but you might be able to recruit your physician to help you with the appeal and your physician would get farther and might be able to speak to the physician reviewer. I was able to do that a number of times, although I had to start with the staff person. One thing I did, which was very useful, is I would tell the reviewer that I was going to put their name and phone number into the medical record. Their initial reaction was, “you can’t do that.” And I said, “yes I can.” If I got to speak to a physician reviewer after going over the case, I would ask them “as one colleague to another, what would you do if you don’t agree with what I’m proposing?” That question usually stun them. They would stop for a little bit and say, “well I guess you’re right, we’ll go ahead and approve it.” So something for your physician or your provider to keep in mind if you get to that point.
Yeah, don’t be afraid to go up the ladder, you know, if you’re talking to somebody and you’re not getting what you need go to the supervisor or just is high up in the chain of command as you can get.
And remember, keep all the events that happen with all the pertinent details, including names and positions and phone numbers in your diary. That may be invaluable later on.
Yeah, again, as I said you know, if the most, more often than not, the insurance company will change their mind for the initial decision and approve your care. But if not, the next step is formal appeals. They involve medical review and they can be very complicated in time consuming. So let’s hope you never have to get to that point. And again, let’s restress that you need to keep records of everything you submit for your own records
And keep copies.
And keep copies. Yes.
The level one appeal, you can file those for any reason, although it will usually be a disagreement about medical care between the insurance company and your provider. However, once you get denial, you have 30 days to complete your appeal letter for requested care that you haven’t received. If it’s for care you’ve received but is not being paid for, you have 60 days for that appeal. So this level one appeal goes to reviewers at your healthcare insurance company not involved in the initial decision, some of whom actually may be physicians as well. They’ll look over all the information, including any additional information provided by you and your primary healthcare provider. So that’s a very important distinguishment is don’t go with just what you sent in your appeal letter. Any new information you or your provider can come up with between the two processes should be included in the appeal letter. This information that’s important connect includes a copy of the original denial letter, which should have a detailed explanation of the reasons for denial along with any supporting medical evidence that they may have accumulated to result in the denial. You also should look through your plan’s external evidence of coverage to see if there is any detailed explanation of what the company considers medically necessary that they ignored when giving you the denial. Again, get the names and titles of anyone you contact and keep detailed notes, complete all the forms that they send you — can’t really skip any of them — and include all the details that they ask for. And Rich talked about if you have somebody doing this for you, you actually need to have a letter yet you signed that gives permission for that person to work on your behalf for the appeal.
So the first thing, this sort of place to start is always with your insurance company. They will provide you with the details of their level one process. It’s always good to ask for advice and assistance from your healthcare provider, your insurance representative, human resources where you work that may be in charge of the insurance policy, or outside organizations can help. They can include healthcare.gov, Patient Advocate Foundation, or the Alliance of Claims and Assistance professionals if necessary. And we can put the links to those sites in the transcript of the podcast.
The time that it takes to make a decision may depend on the nature of your condition, but if this was an emergency situation, you can request an expedited appeal which requires the insurance company to make the decision within 72 hours. Otherwise they usually need to react to the appeal within four business days. If you do have an appeal that’s for treatment you already had, call your provider and say, “don’t bill me yet for this. Let’s see where the appeal goes before you resolve that.” And if your appeal is for unapproved treatment that you’re requesting, make sure that you file your appeal in enough time that you’ll avoid any complications that may happen because of delay of further treatment.
Okay, let’s say you’ve done all that and they still give you a denial. This is when you move on to the external appeal where you have an outside reviewer look at your case. Now the important thing to remember about the external appeals is that they are only going to do review of denials that are based on medical conditions. So any form of medical error or disagreement with the insurance policy details are not going to be reviewed at a level two review. It’s all based on the disagreement between you and your insurance company on medical treatment. You can also do the external appeal if you think that the insurance company didn’t do the appeal in good faith. So you can look for information that may indicate that it was not in good faith and they’re trying to deceive you if you see any fabricated or misleading evidence that doesn’t agree with current medical literature. If they refuse to accept evidence from reputable sources, they’re really not dealing a good faith with you. If they’re refusing to conduct investigation or unreasonably delaying the investigation, or they have an unreasonable insistence on minor procedural or minor bureaucratic requirements that are it making harder for your appeal or basically anything else that makes you think they’re stalling. However once you determine that the appeal is appropriate, some of the medical considerations can include whether or not a treatment is medically necessary, experimental or investigational, whether a particular treatment — whether it’s non-formulary out of network not allowed — is the best one for you and should be covered. They can also overrule any denial involving medical judgment where you or your provider disagree with the healthcare company. They can also review it if your insurer claims that you gave false or incomplete information when you applied for coverage or that your insurance company wasn’t acting in good faith when they did the review.
A note, any and all details for the filing, although in most cases the file needs to be completed within four months of the denial of the internal review. So again, from the level one to the level two, if there’s any new information that you garnered between those two, make sure you include that in the level two appeal. If this is an emergency situation, you can even file a level two appeal before you get the results of the level one of you. And again, if it’s her emergency or urgent situation, the deadlines are 72 hours rather than four months. Once the external appeal is sent in, it will complete it as soon as possible. But depending on the severity or nature of the condition, the maximum that it can take is 45 days. So to start the process, you can ask the information from your insurance company, but there are also a couple of websites you can go to that allow you to start the process without your insurance company’s knowledge. You may want to ask your insurance company for help, but in a lot of cases if you’re not trusting of them, there are other ways to go about filing an appeal. One is visiting the website externalappeal.cms.gov. There are also a couple of toll-free phone numbers you can use 1-888-866-6205 or fax it to 1-888-866-6190.
Once the level two appeal is done and they overturn the insurance company, they are legally required to accept that decision and they have no further ability to deny your care. One less consideration that doesn’t really, it kind of goes along with this, it doesn’t fit with the appeal process, but it’s important to remember that your health insurance is a legal contract between you and your company and if broken can result in a lawsuit. So if you really think the insurance company didn’t appropriately review your appeal, it is a breach of contract and you can consider them acting in bad faith. You can then turn around and make a tort claim. Tort claims, unlike contracts, can result in awards of punitive damages which often exceed the amount of the claim itself. So you also have further places you can go if the insurance company has acted in bad faith.
Couple of thoughts. One is I’ve seen this happen where the provider put down the wrong diagnosis and made a screening test diagnostic or diagnostic test screening, and the coverage was different. This applies to colonoscopies for some reason. Where screening colonoscopy may be covered under one set of benefits as a screening test, whereas a diagnostic one because you’ve had some bleeding for example, would be under a different set of coverage. Again, it’s important to emphasize keep calm, be polite, but do push this if you have to.
As a last point, as I said in the beginning, this process is clearly very laborious and can very easily be outside of the ability of people with chronic illnesses and disabilities. And we’ll definitely link to the resources Mike mentioned that can help those who need help with the appeal process.
There are companies that will handle your appeal for a price. You have to be careful who you sign up with and their guarantees, if any. Nobody can guarantee they always win.
And as always with the physicians, what we say is prevention is the best medicine. And make sure when you get an insurance policy or looking for the insurance policies, you’re truly aware of all the details so that you can avoid ending up in this situation to begin with.
The last segment of each episode, we suggest some of the culture, art, entertainment, and social causes we’ve been engaged with to each other and our listeners. This episode is going out on Thanksgiving, so I just want to suggest everybody donate to a local food pantry and sometimes better than donating canned food is donating money to food pantries so they’re able to buy fresh fruits and vegetables which aren’t able to come in canned and also don’t have a long shelf life So donating them isn’t always the best case. But donating money so they can buy them for unhoused people or just people who need access to food pantries is very valuable.
Thank you so much for listening to this episode of Health Savings News. Please subscribe, rate and review us on Apple Podcasts or wherever you’re listening to the show — it really does help. You can follow @Needy Meds on Facebook, Instagram, LinkedIn, YouTube. You can follow at @HealthSavinPod on Twitter (for as long as Twitter stays around) for updates specific to this podcast and send questions, comments, and topic suggestions to firstname.lastname@example.org. Our music is composed by Samuel Rulon-Miller. His music can be found at musicisadirtyword.bandcamp.com. The Health Savings News podcast is produced by me, Evan O’Connor. All the sources we used in our research can be found in the episode’s podcast description on our website or your podcast app of choice. Health Savings News is not intended to substitute for professional medical, financial, or legal advice. Always seek the advice of a qualified healthcare professional, or appropriate professional with any questions. Views expressed on Health Savings News are solely those as the individuals expressing them. Any views expressed do not necessarily represent views in Health Savings News, other contributors, the NeedyMeds organization, or staff. Thanks again for listening. See you in two weeks with our next episode. Have a happy Thanksgiving.