How to Fight an Insurance Claim Denial

How to Fight an Insurance Claim Denial

Try these strategies if your insurance company denies coverage for treatment.

Hepatitis C (often abbreviated as hep C) is a chronic viral infection that causes inflammation in the liver. Though it often presents with no noticeable symptoms, the disease can cause significant damage to the liver—including cirrhosis, liver cancer and liver failure.

Hep C is treatable, with medications called direct-acting antiviral drugs (DAADs) that can clear the infection in 90 percent or more of cases. However, these treatments can cost tens of thousands of dollars, making them prohibitively expensive without health insurance. And many patients who have health insurance have been denied coverage for hep C treatment.

If your health insurance company denies a claim for hep C treatment—or treatment for any other condition—know that there are ways you can fight that decision and get the insurer to reconsider. Try these expert tips for appealing your insurance claim denial.

Review your plan
"If a patient has submitted a claim for a treatment/service/procedure and it’s denied by an insurance company, the first thing the patient should do is to review their plan document," says Bruce D. Roffe, President and CEO of H.H.C. Group, a medical claims cost-reduction company. "That document defines the obligation of the health plan in terms of their responsibilities to pay for specific health care services."

Check the explanation of benefits
You should also check the explanation of benefits, or EOB, which explains why you have been denied and provides the name and address of where to appeal your claim, according to Adria Gross, a New York State-licensed insurance broker and consultant who runs MedWise Insurance Advocacy and is the author of Solved! Curing Your Medical Insurance Problems. Know that EOBs may contain dense medical or legal language that can be difficult to understand—don’t hesitate to contact your insurance provider and ask them to explain it.

Talk to your healthcare provider
Your healthcare provider’s billing department may be able to help you make sense of an EOB, and your healthcare provider may be able to advocate for you. Insurance carriers don’t always have the right facts. “Asking your provider to submit more details or reword their submission can make a difference," Gross points out.

File an external review
"If your appeal is denied, you may apply to the state or federal government for an external review by a nationally accredited independent review organization (IRO)," Roffe points out. Many insurers only give you a 60-day window to file such a claim. If the IRO decides in your favor, your insurance company is legally required to accept the decision.

Roffe stresses, "It is important that the patient understands that all relevant medical records must be submitted to the IRO so they get a fair review. The onus is on the patient and their physician to make sure that their documentation is complete. In many instances, the review itself is only as good as the information that is submitted."

Write it down
"Keep a detailed log every time you call your carrier regarding a claim," Gross says. "Record the date, the names of the people you speak with, and exactly what was said. Keep copies of all written correspondence and keep the facts of your case handy, including your policy number and claim info. A detailed record can make a difference."

Also make a concerted effort to remain polite, even when the insurer is trying your patience. "No matter what, don’t be confrontational or rude. It can hurt your case," she says.

Use outside resources
When your efforts don’t seem to be having any impact, you may want to hire a professional patient advocate for help. The Patient Advocate Foundation offers a wealth of advice and helpful resources and negotiates or advocates on a patient’s behalf as needed.

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