Reclaim your health with us! This article discusses medical bills and covers:
- What is an appeal for a medical bill?
- Why insurance companies deny covering medical services
- How to file an internal appeal (with your insurance provider) for a medical bill
- How to file an external appeal (with a non-biased third party) for a medical bill
- What is a grievance, and how is it different from an appeal?
What is an Appeal?
Did you know that when your insurance company denies a claim, you have the right to request that they amend the cost of the resulting bill or reconsider it altogether? This process is called an appeal. Every patient has certain rights that hospitals publish and make known to them, and appealing payment decisions is one of them.
There are specific procedures to appeal medical bills with your insurance company, and these fall under two categories: internal appeals and external appeals. To start the process, you’ll need to review the documents you’ve received from your insurance company. The insurance company must notify you in writing and explain why you received a denial, using the following parameters: (healthcare.gov/appeal)
· Within 15 days if you are seeking prior authorization for a treatment
· Within 30 days for medical services already received
· Within 72 hours for urgent care cases
Note: Your health plan cannot drop your coverage or raise your rates because you ask them to reconsider a denial through the appeals process.
Why Do Insurance Companies Issue Denials?
It can be incredibly frustrating to learn that your insurance company has denied a claim. Insurance companies issue denials for a wide variety of reasons, including:
- The benefit isn’t offered under your health plan. Examples of services that aren’t typically covered under health plans can include cosmetic surgery, weight loss surgery, and chiropractic care.
- The medical problem is pre-existing. Some pre-existing conditions are covered, and more are required to be covered by law than ever before.
- The service or treatment is deemed “not medically necessary.” This includes procedures that are repeated. An example would be if you received a colonoscopy this year and last year, while the general recommendation is to only get one once every five years. Your physician could provide proof of a condition that made the procedure necessary.
- The requested service or treatment is an “experimental” or “investigative” treatment. Some cancer treatments fall under this category, or certain treatments that are used in ways other than what they were originally designed for.
- You are no longer enrolled or eligible to be in the health plan, such as an employment change, or eligibility for other coverage.
How do I file an Internal Appeal?
Here are 3 ways to get started on filing your appeal:
1. Complete all forms required by your health insurer. These forms are often found on their website, or they will mail them to you. Be sure to include the claim number and your health insurance ID number. You can also include any documentation that you want the insurer to consider, such as a letter from your doctor.
2. Submit a formal letter requesting the appeal. Make sure to include all the relevant details, including your name and contact information, claim number, and health insurance ID number.
3. You can contact the Consumer Assistance Program in your state to file an appeal for you (most states provide this). Visit LocalHelp.HealthCare.gov to find help in your area.
Remember to always keep copies of all forms and letters you send, and be sure to send them by certified mail.
Deadlines: You must file your internal appeal within 180 days of receiving the denial notice from the insurance company. Your internal appeal MUST be completed by the insurance company within 30 days if the appeal is for services you haven’t received yet. It MUST be completed by your insurance company within 60 days if the services have already occurred.
How Do I Apply for an External Review or Appeal?
If you receive an unfavorable decision from the internal appeals process and still believe that you should dispute the denial, you still have an option! The next step is to send your disputed claim for external review. External review uses a non-biased third party (usually an independent physician) to review the claim. There are two steps in the external review process:
1. File a written request with the insurance company within four months after the date you receive a final determination from the internal review. The information to file this should be found on your internal appeal decision letter. You can also check the state list here: https://www.cms.gov/CCIIO/Resources/Files/external_appeals
2. An external reviewer issues the final decision. An external reviewer either agrees with your insurer’s decision, or overturns it. Your insurer is required by law to abide by the reviewer’s decision.
To improve your chances of a successful external appeal, keep all copies of your external review documents and send your written request by certified mail. If you need help with this, a representative can file the external review for you. Simply contact your state’s Consumer Assistance Program. https://content.naic.org/state_web_map.htm
What is a Grievance and How Do I File?
Once you have an itemized bill, you also have the right to an explanation of charges that you are unclear about, and you can dispute those charges through a formal process called a grievance. A grievance is a formal, written complaint or dispute that is handled through the patient advocate or quality department. Do not confuse a grievance with an appeal; the grievance has to do with the hospital’s side of the matter, such as charges, services rendered, and quality of care. Remember, appeals dispute decisions made by insurance companies about payments for services, or approval for services.
You can file a grievance in several ways, but you’ll need to use the word “grievance,” which carries more weight than “complaint” in the healthcare world. Complaints are for less serious matters, such as the room temperature or food quality. Hospitals must maintain a grievance committee, made up of representatives from administration, billing, quality, and clinical services, that review all cases. The committee must also meet frequently in order to ensure timely investigation and resolutions.
If you are able, it’s helpful to go to the hospital with your bills and information in hand and ask to speak to the patient advocate about a grievance. The front desk should direct you to the appropriate office. If you bring your organized notes and documentation, it’s much easier to explain your case to the patient advocate with appropriate details to help him or her understand your issue.
If you are not able, this can be handled with a phone call, but be aware that the patient advocate will usually take down all of your information and then pull your records to do some research. For this reason, face-to-face communication is often easier and facilitates a quicker resolution.
Accreditation conditions of participation for hospitals dictate that grievances receive a written response within 7 days. This does NOT mean that you will get a final answer within 7 days, but you will get an update and a plan of investigation. The committee will meet, evaluate next actions with your request, and then communicate that via a letter. Actions may take time, because it may involve evaluating your medical records, contacting your insurance company, or even talking with your physician. You will be given information in writing about the resolution of your dispute, including the investigation and if all or part of the charges are reversed.
How to Obtain Detailed Bills and Medical Records
Upon request, hospitals and other medical care providers must provide patients with an itemized bill of each charge or service provided. This can be requested by phone through the billing department.
If you’d like to request printed medical records, a form must be signed to release those records to you. This system is put in place for your protection, as medical records are protected from access by anyone except you or your designee. You may have heard of the laws that fall under HIPAA (Health Insurance Portability and Accountability Act). This law was passed in 1996 and protects your personal health information. When you request medical records, you’ll typically need to designate which procedures or time frames you would like to be included. If you don’t have a specific service in mind, it’s to your advantage to request records by time period rather than by procedure or physician, as you’ll get a more comprehensive record. Be prepared – medical records are large and very detailed! You may receive hundreds of pages.
