Once you have health insurance under the Affordable Care Act, you can begin receiving health care and filing claims to your insurance carrier. A claim is a request for coverage. You or your health care provider will file a claim to be reimbursed for the costs of treatment or services. But sometimes, the carrier will deny coverage. What can you do if that happens?
“People should know that the Affordable Care Act gives most consumers the right to challenge their health plan’s decisions and that their insurer is required to send instructions about how to initiate an appeal when it denies payment,” says Paul Rooney, vice president of carrier relations for eHealth, an online marketplace for health insurance plans. “It also needs to spell out any deadlines for doing so.” ACA law gives consumers 180 days from the date of the denial to file an appeal, and there are other deadlines insurers are required to adhere to in responding, according to Healthcare.gov, the website of the U.S. Centers for Medicare and Medicaid Services, or CMS.
Filing claims appropriately in the first place is the best way to avoid a denial of coverage. “The first trick is to stay in network,” says Karen Pollitz, a senior fellow with the Kaiser Family Foundation. That means using only the doctors, pharmacies, hospitals and other services that are part of your insurance plan‘s network of preferred providers. “If you do that, the provider will file the claim for you. When you go out of network, you have to file the claim yourself, by paper. It can be a lot more complicated,” Pollitz says.
If you haven’t enrolled in coverage yet, the open enrollment period is the time to carefully review your plan’s network to be sure it includes the providers you want to work with. You can usually find information about which doctors and services are in your plan’s network on its website, or you call the insurer directly.
“Also, take the time to understand your insurer’s rules of engagement,” Rooney says. “Make sure, for example, that you follow your insurer’s drug protocol, which may require you to first try a different drug than the one your doctor prescribed. If you’re going for a procedure or surgery, it’s a good idea to first get both a letter of prior authorization from your insurer and confirmation in writing from your doctor that the procedure he or she plans to perform is the same one your insurer approved.”
If your insurer denies coverage, it must issue an explanation of benefits, or EOB, in writing and explain why. Insurers’ decisions about whether to pay for care are typically based on whether the care is considered medically necessary, Rooney says. “Often, claims are denied because there wasn’t enough information to demonstrate the medical necessity.”
If your claim is denied or underpaid, you have ways to appeal. “The EOB must include information on how (to appeal),” Pollitz says. Rooney says that the first thing to do is ask your doctor for supporting materials. “If you had surgery, for example, ask the surgeon’s office to send the official report of the procedure,” Rooney says. “That may help spell out a discrepancy between the service performed and what was paid by the insurer.”
Sometimes a denial can be based on a simple error in medical coding. There is a procedural code associated with every type of medical care provided. The code your provider uses when submitting a bill must match the code your insurer provided on the pre-authorization letter. If it doesn’t, your doctor needs to resubmit the bill with the correct information.
If your insurance company still denies your claim, you can appeal the decision. There are generally two levels of appeals allowed: an internal appeal with your insurer and a review by an independent third party. The insurer reviews and determines the outcome of internal appeals. “Most insurance company medical review boards are staffed with doctors who will help make the final decision on coverage,” Rooney says. If coverage is denied again, consumers may be able to file an external appeal, which is handled by an outside third party and will either uphold the insurer’s decision or side with you. Each state has its own process for external appeals. Contact your state insurance department for details.
To avoid having any outstanding bills sent to collections while you appeal, ask that your case be put on hold while the appeals process is running its course. “Health care providers are usually willing to do that knowing you’re working on it,” Rooney says.
All these processes and procedures can be daunting. Don’t try to navigate them alone. “Enlist someone to help you,” Pollitz says. Many states, though not all, have ombudsman or consumer assistance programs to help. Call your state insurance department to learn more. Most insurance brokers also work with their customers to address claims problems free of charge, Rooney says.
The final piece of advice is, don’t give up easily. “When you are making a claim, you are often sick and don’t have the wherewithal, but in general don’t take no for an answer,” Pollitz says. “If people appeal, often they will prevail. But you may have to stick with it for a while.”
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