How to Challenge a Denied Insurance Claim and Save Money

It is very disturbing when an insurance claim denial arrives in the mailbox. It usually means that the patient is the loser and must pay unexpected money. Do you want to save money on medical claims? You can achieve success if you do your homework and use your skills to analyze the problem. I personally have handled three reversals on insurance claims. I am sharing one of them. If you want to have extra money in your pocket, look at the following example that takes you through the decision making process.

Example: Mr. S. was hospitalized at an outpatient surgery department for a detached retina, which was handled by a skilled retina specialist. The surgery was very delicate and sometimes is not successful. The amount of the claim was reduced, as the insurance company stated that the facility is not a preferred provider.

The following steps take you through the decision process of the challenge to a claim.

Difficulty: Moderately Easy

Instructions

1. 
    
   Claim files

   Read the decision and attempt to resolve it by telephone with the insurance company. If this path is unsuccessful, study the policy to see if there is reason for appeal.

2. Discuss it with the physician and obtain input from friends, relatives, or anyone who has some medical knowledge or experience with appeals.

3. Make a decision. Be sure to adhere to the time frame for appeals. Contact the physician to request a letter from him explaining the reason for using that facility. In this example, the reasons were that the facility has superior equipment to other facilities, that the surgery is delicate and not always successful and that the provider is the only retinal specialist in the city. He uses only that hospital. Use a similar procedure for your own situation.

4. Write your own appeal letter, following procedure. The insurance company usually needs the date of service, name of patient, insurance policy number, claim number, and provider's name. Be sure to explain the circumstances from the discovery of the diagnosis to the final correction of the problem. Discuss the confidence you have in this physician and facility in this example. Be sure to mention the issue you are appealing. In this case, you are taking issue with the hospital not being a preferred provider. Follow this procedure for your own situation.

5. Forward the physician’s letter and your own letter to the address listed for appeals. If you are successful, you have just saved yourself some money. Continue looking at your insurance claim decisions to save money in the future.

Tips & Warnings

• If a denied insurance claim involves a large amount of money, consider hiring someone to assist with appeal.
• Enlist a capable person to assist with preparation of the appeal letter if needed. The web contains sample appeal letters. Query “sample appeal letters
• Follow through if the insurance claim denial issue is not resolved in a timely manner during the appeal process.

Resources

• How to Save Money by Challenging a Denied Insurance Claim

[ajmaddox]

on 10/21/2009 Great article. This is usually a long process, but worth the time and effort.

[bailey4]

on 9/28/2009 Important information on how to challenge a denied insurance claim. 5*

[bailey4]

on 9/28/2009 Important information on how to challenge a denied insurance claim. 5*

[davida8575]

on 9/26/2009 Good info here. I hope I never have to do it though.

[bellerose]

on 9/8/2009 Excellent advice for getting some expertise on filing an appeal in the correct form and on time. 5*