'7 Good Reasons to File an Insurance Appeal: Expert Advice'

By Martine G. Brousse (not AI!)

Patient Advocate, Certified Mediator

AdvimedPro

February 14, 2024

Last year, the Kaiser family Foundation published an article exposing a 17% denial average of claims by insurance plans (some companies' rates are higher). More shocking was the fact that less than 0.2% of those were appealed, and therefore patients got NO opportunity to dispute and overturn the decisions and claim processing that cost them money, and blocked access to the care they needed.

Too many patients are unaware of their Right to Appeal, and even fewer use it. This must change!

A. WHAT IS AN APPEAL?

your right to disagree with a negative decision issued by your insurance in regards to eligibility, coverage of medical care, or payment of a claim
your right to request that your insurance review (and overturn) its denial, rejection of coverage, adverse decision or refusal of financial responsibility
your right to request a reconsideration of a decision based on medical records, documentation, facts, circumstances, legal mandates, terms of policy, medical policies, previous approval and more
right to force payment, coverage, approval, responsibility by your plan after an original “no”.

B. WHEN TO FILE AN APPEAL WITH YOUR INSURANCE?

The 3 basic types of denials are:

Rejection of Eligibility for you or your dependent(s)
Denial of coverage for a medical service or item
Incorrect processing of a medical claim including denial of payment

Unless your insurance has a valid, proven, confirmed, logical and legal reason to impose the financial cost of a medical service to you, or to reject approval for it, filling an appeal should be considered.

C. The 7 GOOD REASONS TO APPEAL:

1. Rejection for "no eligibility":

Your new plan does not show you or your dependent as eligible: this often happens in January, when insurance companies, dealing with a backlog of new members and paperwork, cannot update systems and data bases in a timely manner. If calls to HR or the eligibility dept have failed, and you have proof of enrollment, filing an appeal should resolve the matter.
COBRA has not kicked in despite filing the paperwork and paying premiums to the administrator: (COBRA= extension of coverage after you and your company have parted ways, but that allow you to keep the plan for at least 18 months as long as you pay the premiums). If you have confirmation from the COBRA administrator that you are eligible and premiums were paid to the insurance, file an appeal to get coverage re-instated and your claims paid.
Your (new) insurance has not yet received or applied premiums to your account. Whether through the COBRA administrator or through your direct payment, filing an appeal with proof of payment (credit card statement, cashed check) and details of delivery (USPS tracking number, online payment) should get any lapse in coverage reversed.

2. Rejection for "no coverage":

A specific device, item, procedure, service or type of medical care are denied as “not a covered benefit”. What is the exact reason: was the drug denied because a generic version is available? Is it an exclusion listed in the policy? Was the maximum number of visits per year exceeded? Was the device not covered because the diagnosis listed is not specific enough or does not apply? If no clerical error was made, an appeal may be needed.
File an appeal showing the terms of policy include coverage for the service/item, or that a medical policy denying it is obsolete
File an appeal showing the treatment is considered "Standard of Care" in the US, or that emergency conditions warranted it
File an appeal documenting the specific medical circumstances that override the policy: you are very allergic to the generic Rx, your autistic child needs - and has been prescribed - more than the 24 speech therapy sessions allowed in a year, the patient has had a stroke and needs a walker to avoid falling while ambulating. Medical records are a must.

3. Rejection for "lack of medical necessity":

Has your provider ignored the insurance's requests for medical records? Sending them should resolve the matter. No appeal is needed.

But the office or you may need to file an appeal to obtain a specific authorization or get a claim paid:

Gather evidence proving this service/surgery/Rx/treatment was the only one advised by your physician(s), the only one safe and effective, or was the last chance for you to regain your health or avoid irreversible damage.
Always include a letter from your physician (or other treating Drs) and medical records, explaining the rational behind the decision to order it and why it is a prudent, medically indicated decision that any other physician facing the same facts would have made ("medical necessity")

You may also have to prove that the specialist you consulted and whose claims are now denied or are underpaid:

· had the best credentials, availability, training, experience for your (rare) condition,

· and that no "in network" or insurance- contracted provider could render the level of expertise or care needed, or could give you a timely appointment.

4. Rejection for "lack of authorization":

It is not a patient’s job to obtain an authorization for a surgery or “big” services like chemo, a surgery or a Rx. Most insurance companies would not allow them to do so anyway.

But if the office or facility decline to help for lesser services, or if they are out of network, you may need to provide your insurance with the medical records showing why this medical care is/was necessary, safe, effective and indicated.

Emergency conditions: no auth would be needed (although a notification within 24 hrs might)
Explain that special circumstances prompted immediate action without a pre-authorization: holiday, outside of insurance utilization management phone hours, remote location, no insurance card on you at the time of ER services, lack of billing staff at the facility or office due to Covid or time of night, etc
If the facility or physician are out of network, explain why you used their services and theirs only (competence or unique expertise, lack of in network alternatives, excessive delay to access care otherwise, etc).

5. Rejection as "experimental" or "not FDA-approved"

The assistance from your Dr or facility is crucial here. Were you informed that a treatment, drug, device or procedure were not considered Standard of Care in the US? If yes, you may have a hard time winning an appeal but it is not impossible.

If a Rx off-label use (not yet FDA-approved) has been shown in trials, studies and peer-reviewed literature to be safe and effective, use that documentation. Your disease may be rare. You should not be penalized by the scarcity of trials or non-action at the FDA level due to the lack of research, scarcity of national interest or funds, or shortages of drugs or alternatives being introduced to the market.
Check the current FDA stand on your denied procedure or treatment. Insurance medical policies are not updated quickly, and something denied yesterday may be FDA-approved today.

6. Rejection for "out of geographical area":

All HMO and a number of EPO or PPO plans have exclusions for services rendered out of state or outside your assigned medical group.

Do file an appeal if:

services were rendered under emergency circumstances
the out of area/state provider you consulted is an authority for your (rare) condition
this specialist is the only one able to offer an appointment within a short period of time to avoid serious consequences to your health
the lab you had to use was the only one able to perform the special tests your Dr ordered or if results had to be immediate and therefore was sent to an out of network lab
there is no comparable facility or available specialist within 30 miles from your residence. In a large urban area, the 30 miles translate into 1 hour in transit
your surgery or treatment required a high level of care which the local facility was unable to meet

Patients living in rural areas are particularly at risks of such denials. These should be vigorously contested.

7. Processing at the "wrong rate":

Let’s remember that claims are processed by algorithms and now AI, based on a provider's Tax ID number, and the procedure and diagnosis codes.

If a pre-authorization had been obtained and then ignored, and the claim denied or underpaid, a call to the Claims Dept should get that claim reprocessed. If not, an appeal had great chances of a win.
If a provider or facility were paid as Out Of Network but your policy pays In Network (higher) rates for those specific circumstances, do appeal! Emergency conditions for example are often ignored when most policies cover those services at the highest rate.
The new No Balance Bill federal law forces many plans to cover certain services and circumstances at the highest rate. Some similar bills at the State level do the same. Your insurance may have to abide by them and an appeal must be filed. Violations can and should be reported to the appropriate authorities.
A provider may have cancelled their contract. If treatment started when there was one, appeal for “Continuation Of Care coverage” and the higher payment rate. Do show that interrupting or delaying care to look for a comparable in network provider would negativity affect your health. Insurers routinely continue to cover treatments such as chemotherapy or ABA therapy for an autistic child at the highest rate.

8. A WORD OF CAUTION:

1. There are so many other reasons to file appeals, and many more where the right of appeal does not apply.

7 good reasons to file an insurance appeal

2. Keep in mind that the number of appeals you can file is limited to 2 (with plans administered by the State) and usually 3 with ERISA self-funded plans (administered by the Dept of Labor).

3. I never recommend to file an appeal over the phone with a rep. First, they will write what they understand, not necessarily all you tell them. Secondly, and most importantly, you cannot attach any document, medical record or other evidence to support your appeal. These appeals almost always result in denials. Do not waste your appeals!!

This is where a patient advocate specializing in the billing side of things and with appeal experience, is a great ally to have on your side.

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.