The shooting death of UnitedHealthcare CEO Brian Thompson on Dec. 4 set off a flurry of social media comments and news stories about the frustration people feel about healthcare payment in the United States.
Many have shared personal anecdotes about negative experiences with their health plans and expressed anger over the difficulty of denials for care.
“For any patient who’s ever received a denial in the mail after they’ve received treatment ... that is a shocking moment because many times, they’re not sure how they’re going to pay that bill,” said Todd Nelson, director of partner relationships for the Healthcare Financial Management Association.
Patients have several options when faced with a denial from their health plan.
Realize that a denial is often not a final decision. A recent study found that half of Americans who challenged a claim denial said their health plan ultimately approved their care. However, only 43% of adults who received a denial went on to challenge it. Nearly half of those who didn’t challenge a denial weren’t sure they had the right to do so. Be assured that you do have that right. The federal law known as the Affordable Care Act gave people the right to appeal decisions made by their health plans, regardless of the type of insurance they have or what state they live in.
Read the denial letter carefully. When a health plan denies a claim, they send you a letter, called an explanation of benefits (EOB), that outlines the services that were billed, the amount covered by insurance and reasons for any charges that were denied.
Call your health plan and speak with a customer service representative. They may be able to provide more details about why the claim was denied. In some cases, such as missing or incorrect information on a claim, the situation can be resolved by calling your provider’s office and asking them to correct the information and resubmit the claim to your health plan.
If your calls don’t result in a pathway toward approval, prepare to file an appeal. An appeal is a formal request that your health plan reconsider their decision to deny payment. Details about the appeal process are included in the EOB that you received from your health plan. An appeal is your opportunity to provide additional information and medical records to support your claim. Contact your doctor or hospital to ask if they will file the appeal on your behalf. In many cases, they will.
If the claim is not approved on appeal, you have the right to file for an external appeal. Also known as external review, this is a review of the health plan’s decision by an independent third party that is not affiliated with your health plan and has no financial interest in the outcome. For more information, visit externalappeal.cms.gov or call 888-975-1080.
Beginner tip
If you have already received a bill from your provider, ask the provider’s office to put your account on hold while you go through the appeals process. This process takes time. You will want to prevent the bill from being treated as overdue while you’re waiting for your health plan’s decision.
Advanced tip
If a denial is due to incorrect billing codes, your provider can correct the codes, provide supporting information, if needed, and resubmit the claim. For example, certain screening tests, such as a mammogram or a colonoscopy, are covered by health plans as preventive screenings that have no out-of-pocket costs if certain requirements are met. But if the procedure is incorrectly coded as a diagnostic test (usually meaning you have relevant signs, symptoms or history of the relevant disease), you will need to meet your deductible before the health plan payment kicks in and you will also be responsible for your copay and coinsurance.