That denial letter, lying on your counter, probably gives you a burning sensation somewhere in your body. But the rejection is not the end of the road here. They want you to leave after being intimidated by all their lawyer terms. But you will make them pay you what they owe. Consider the situation as your first fight with a boss in life and surely, you have enough XP to win. 💪
Firstly, it is important to understand that “denied” does not mean that the procedure was never done. Often, it is a strategy used to see whether you are persistent enough. Denials are a daily routine of most insurance adjusters. Indeed, they really believe that a lot of customers will just give up.
Do not grab for your wallet immediately. Use a highlighter and some ink in a bright color and take the explanation of benefits, that is the so-called EOB. It is what you should use to find out the reason for your denial. Maybe, they believe that the procedure was unnecessary in a medical sense, or maybe they want to prove that you suffer from some kind of preexisting condition.
Look for the codes which sound more like the codes from a sci-fi movie than the code of a doctor’s office. The common codes of denial are 96, implying the non-covered charges, and 18 – the duplicate claim. Google the particular alphanumeric sequence as soon as possible. Your weapon against their bureaucracy is knowledge.
After having found the mistake, it is time to contact the customer service department. It will take a lot of your patience and persistence. Note down every person you talked to, including his name and the exact time of the calls. In case the person says that your call is recorded for quality purposes, tell him that you also record this call.
If the person on the line cannot help you to solve your problem, ask to speak with the person responsible. Do not accept any vague promises that they will call you back. Hold the line and listen to their terrible hold music till the manager picks up the phone. You have nothing else to do right now.
The actual documentation will be your paper trail, making insurance executives to shake in fear. Write the letter of appeal to your insurance company on your computer. Even though you do not have a Microsoft Word license, there is free software called LibreOffice. In your letter, you should mention the policy number, the date of the service and the reason for denial, as stated in EOB. Write the letter professionally and say how shocked you are by their misinterpretation of the information.
Prepare your documents as the prosecution prepares the evidence for a trial.
You need the notes of the doctor explaining why the procedure was necessary for your health. Ask your physician to write the so-called “letter of medical necessity”. Gather all your receipts, laboratory results and notes of the nurses. Send them all certified via mail with the return receipt requested.
If the appealed mail did not help, do not think that everything is over or try to borrow money with the high interest rate. There is the internal review board in almost every insurance company which reviews the second-level appeals. This process involves the evaluation of the decision made by one insurance employee by another doctor employed by the same insurance company. Even though it sounds as a conflict of interests, you still should use this procedure to proceed to the next step.
Send the new letter to the internal review and note the fact that the denial contradicts their policy language. Quote the particular section of the contract which includes the description of the treatment you received. Emphasize that denial leaves them vulnerable to the litigation and the bad publicity in social media. Insurance companies really hate being disrespected and dragged through the mud by a young person.
If you have failed again at the state level, you can submit a complaint to your state’s Department of Insurance. The government agency regulates the insurance carriers and aims to protect you. The filed complaint will start the external review when the independent third party will review your case without financial interest in denying you. When the state becomes interested in your case, the insurance companies start finding miraculously the needed funds.
You can also hire the public insurance adjuster which takes a certain percentage of your recovery. If your hospital bill is big enough, the cost of hiring them can be justified by the fact that they will handle all of the paperwork. Find local specialists or ask your parents to introduce you to someone who knows something about insurance disputes.
Never forget that silence is your enemy in this whole process. Insurance companies operate according to the tight schedule, often giving you only 180 days after rejection to file an appeal. Put the particular dates in your calendar application with annoying alerts. The missed window means that you gave them the right to deny you without discussing the matter.
You can feel yourself a troublemaker, but consider the money and your future credit score. Use that polite but persistent attitude you had when asking your high school principal for additional bathroom passes. Stand your ground, present the facts and do not back down until they change their mind. Eventually, the amount of your work will persuade them to cut a check and get rid of you. 🤷♂️