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How Does the Health Insurance Appeal Process Work? An Expert Explains

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Published on April 30, 2019

How do you appeal a health insurance coverage denial? How long does an insurance appeal take? Health insurance expert Stacey Worthy from Aimed Alliance walks through the procedure for chronic lymphocytic leukemia (CLL) patients with a denied medical claim who wish to file an appeal. Stacey also explains how patients can use social media as a powerful tool to advocate for care. Watch now to find out more.

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Transcript | How Does the Health Insurance Appeal Process Work? An Expert Explains

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you’ll get care that's most appropriate for you.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:                     

Stacey, let’s go through the process because some of our folks have been asking—the appeal process. So, you are denied coverage, or it’s gonna be really high co-pay, or whatever.

...scan or maybe some—take us through the process. Just walk us through.

Stacey Worthy:           

Oh, okay. So, you’re gonna get a—if you’re denied care, you’re going to get a letter in the mail that explains that your care was denied. At that point, you’re gonna wanna read it, review it, figure out what was the reason that they denied the care, let your doctor know, and then you’re gonna call the insurance company. And, as Eliot said, you wanna take a lot of notes here as to who you’re talking to, what they told you, and everything that happens.

Make sure you put the date down, time, everything, the name of the person, and find out what the appeals process looks like, try to get more information about why it was denied, what the next steps are. Then, you’re gonna work with your doctor to file an appeal. So, it might be a formal appeal where the doctor needs to submit some type of form or documentation proving that the treatment was medically necessary or whatever was going on, whatever reason it was denied.

At that point, they’ll likely give you another letter, and they have time limits on when they’re required to respond. The time limits might be different per state, but typically, it’s no longer than 15 days, and in some instances, they’re required to allow you to remain on your treatment while you’re appealing, so it really is state by state. Unfortunately, it differs by state.

Eliot Finkelstein:        

And company by company.

Stacey Worthy:           

Exactly. That’s absolutely true. So, at that point, they’re gonna give you another letter. Either it’ll tell you that they granted the appeal, whether fully or partially, or that you were denied. If you were denied again, that’s when they should give you a letter that gives you a list of independent reviewers. So, this is the private entity—or, it’s an entity that’s not affiliated with your insurer, and you can appeal to this independent body at this point, and you can ask them to review. 

They’re gonna do another medical review and determine whether the insurer was justified in denying your claim or not. If they deny, then that’s when you’re going to want to go to either your insurance commissioner or attorney general, and they’re gonna be looking at it from more of a consumer protection perspective to see if they did something that was in violation of a consumer protection law or unfair or deceptive, and then hopefully get you coverage that way.

But, as I said—as we both said, you can always try and threaten ahead of time. When you do that very first informal conversation, you can threaten to skip right to that complaint process, and maybe they’ll approve the treatment sooner than later.

Eliot Finkelstein:        

On mine, Andrew, it’s very specific. You have to do the written appeal first, and then if you get denied, my second appeal goes directly to the state board. Some people do other things.

Stacey Worthy:           

Yeah, absolutely. That’s a very good point. So, you’re gonna wanna find out what the process is from your insurer, and then make sure you follow that to a T because if you don’t follow the process, they can find any reason to deny you 

Andrew Schorr:          

Okay. And, if you’re a Medicare patient and it seems like they’ve got these big books—is there any appeal process within Medicare?

Stacey Worthy:           

I’m not entirely sure about that, so unfortunately, I can’t give you more information there.

Andrew Schorr:          

And then, what about – you mentioned going to the media or even—a lot of us here are on the internet a lot. What do we do about going to social media? In other words, if we’re having a beef with Blue Cross of whomever or whatever the policy, should we do @BlueCross or look it up somehow and just say, “I’m having a big fight, I’m living with a cancer—a leukemia—and they’re giving me a hard time about the coverage that my doctor thinks I need”?

Stacey Worthy:           

Yeah, absolutely. I would recommend tagging your insurer, and then tagging all the big patient advocacy groups as well, and Patient Power. Tag everybody, because they can amplify your voice, retweet you, and get you a lot of coverage, so I think it can be a very powerful tool.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.