Making Sense of Insurance Appeals

I recently attended a presentation on managing cancer costs. It was chockful of helpful hints. I share some of what I learned here.

1. Keeping track of costs

While the Explanation of Benefit (EOB) form you receive from the insurance company can be very confusing, it is an important document. Be sure to monitor it closely because, while it is not a bill, it details the services for which you will be billed.

One reason insurance is so confusing is because of the way bills are paid. I get notices from my insurance company showing where bills from a year ago are just now being paid. It is difficult to keep track of, but you need to do it.

It is very helpful if you keep a diary or calendar that details every visit you make to a doctor. Include who you saw, what kinds of tests were performed, and whether you received chemo (and if you didn't, why not if it was scheduled).

When the EOB arrives, compare the services it shows were rendered with your calendar entry. If there is a discrepancy, call your clinic right away so errors are corrected in a timely manner. Errors may occur when the humans inputting codes hit a wrong key or you are billed for chemo that was scheduled but that you didn't get because your blood values were too low.

As the bills for services begin to come through, compare them to services delineated on the Explanation Of Benefits form. Make sure you are not billed for any services that you did not receive.

2. Appealing decisions made by the insurance company

It is nearly inevitable that a time will come when your insurance company denies a claim or a service recommended by your doctor. Do not despair! It is possible to appeal their decision. Chances are good that you will ultimately prevail.

Always, always, always appeal an insurance denial. Here are the steps you should take:

• Check with your medical team. Your doctor's office will often handle the appeal for you. In many cases, the insurance company simply needs more information before they approve a cost or service.
• Appeals are time sensitive. When you are denied a cost or service, you need to initiate an appeal right away.
• Most insurance companies require that appeals are initiated in writing. A phone call will not suffice.
• If your doctor is not handling the appeal, check with the insurance company to find out what steps you need to take to file an appeal.
• Those with Medicare can go to this website for step-by-step instructions on how to appeal a denial.
• If you need help writing a letter to your insurance company to appeal a decision, you can find samples at the Patient Advocate Foundation.

3. Internal vs External Reviews

There are two main types of appeals processes:

• Internal where the insurance company reviews the decision and
• External where a third party is involved in the review.

As you might expect, an external review usually occurs after being denied through an internal appeal. An external appeal may also take place when a denial is life-threatening.

Asking for additional help

If you need help with an appeal and you still work, go to your company's HR department. If you do not work or cannot get the help you need through your HR department, contact your state's Department of Insurance. They can help with appeals to private insurance companies. Frequently, getting the HR department or the state Department of Insurance involved results in a quicker review of the appeal.