Make Your Health Insurer Pay

by Kimberly Lankford


When your HMO refuses to pay for medical procedures you've received, you have lots of ways to challenge your insurer -- and win -- without resorting to a drawn-out court battle. Often it's just a matter of knowing the rules and having sharp enough eyes to point out errors.

You'll have to pick up the phone or write a letter to start the appeals process, which could lead to a hearing with your insurance company or an outside review board. But if you present a strong case, it may never come to that. Follow these procedures to challenge a claim that has been denied:

Get an itemized bill from the hospital and verify that you actually received all the services for which you have been charged. "I once saw a bill that included a charge for a circumcision room," says Pane. "But the baby involved was a girl." Get the hospital to adjust the bill, then notify the insurer.

Keep careful records. Organize bills, explanations of benefits and other paperwork by the dates on which procedures were performed, and make sure everything adds up. "Most of the time this is a bureaucratic fight, and whoever has the better records wins," says Orin. Call the insurer if you have questions, and get everything in writing.

Find out why a claim was denied. You may discover that a procedure was miscoded, or that all you have to do to receive payment is track down a doctor to verify that a referral was made.

Ask for the surgeon's notes regarding an operation if the insurer refuses to pay the whole bill because it's above the customary cost for that procedure. The notes may prove that your case was more complicated than usual, says Pane, and justify the extra charges. Know which benefits are mandated in your state. Most insurers must provide required coverage, even though it may not be spelled out in your policy.

Gather concrete evidence from doctors to build your case. "You can write all the poignant letters you want," says Kathleen Hogue of Twinsburg, Ohio, who handles medical-claims paperwork. "But what really counts is the medical evidence."

Get help if you need it. Some states have an ombudsman's office, or they may refer you to the state insurance department. Others have separate offices for HMO and non-HMO issues. Some will help you through the appeals process, while others merely gather complaints and investigate a company if there's a pattern of problems. The state can't help much if your plan is self-insured by your employer; such cases fall under the jurisdiction of the U.S. Department of Labor. But most states have a general number you can call to find out where to get help.

2003 The Kiplinger Washington Editors, Inc.


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