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10 tips for resolving health plan disputes

Health insurance payments are often denied for treatments that are new, experimental or not deemed medically necessary. Denials also can happen in routine, run-of-the-mill situations that you absolutely should question. Here’s how to proceed if a dispute arises. By Laura T. Coffey.

Are you among the fortunate Americans with health insurance? If so, you’re likely to receive the medical care you seek — but watch out! That doesn’t necessarily mean your health plan will reimburse you for it.

Payments are often denied for treatments that are new, experimental or not deemed medically necessary. Denials also can happen in routine, run-of-the-mill situations that you absolutely should question.

Here’s how to proceed if a dispute arises:

1. First things first: Read the fine print. Sure, there are times in life when it’s better to seek forgiveness than permission — but unless you’re a fan of big bills and giant headaches, this isn’t one of them. Before you go see a doctor or specialist, review your health plan’s rules to see what the plan will and will not cover. Certain aspects of the rules may be remarkably clear, and this might affect your decision to have that permanent makeup tattooed onto your face. If you’re having trouble finding a clear answer in your health plan’s literature or on its Web site, take a minute to call the customer service number on the back of your insurance card.

2. Try customer service if you have a legitimate beef. If your claim is denied or not paid in full and you think that shouldn’t have happened, call your health plan and ask why. It might have been due to a simple administrative error. Have all your paperwork in front of you when you make the call, and remain friendly, reasonable and calm. The tone in your voice should convey the message that of course the two of you will be able to resolve this little mix-up.

3. Document all correspondence. From the moment you call customer service about your situation, start keeping a careful record of each phone conversation and letter exchanged between you and your health plan. You may need it later.

4. Know when to consider requesting a formal review. If customer service doesn’t help you, you can file an appeal with your health plan. In most cases, you must do this in writing within 60 days of receiving the original explanation of benefits. Send your appeal via certified mail.

5. Examine documents carefully. If you launch such a formal review, you may be given access to all the documentation used to determine your benefits. Don’t be too surprised if you discover an error that could change a denial to full payment – it happens!

6. Question rates that seem unreasonable. Most health plans will tell you their fee schedules are not subject to change, but if it seems obvious that a certain reimbursement is especially miserly, call and question it. Most insurers will investigate large discrepancies, and on occasion they will make changes.

7. You can file a complaint. If your health plan won’t help you at all, you may need to alert regulators to your situation. This would involve filing a complaint with your state’s insurance office, attorney general’s office or consumer affairs office. Most states have an umbrella Web site that shouldn’t be too hard to find via a quick Google search, and that site could help you figure out where to turn. You also can search for a toll-free consumer hotline or insurance hotline for your state.

8. Understand when to pursue an outside review. If your insurer denies your claim on the grounds that a treatment is not medically necessary and you strongly disagree with that decision, you can request a review by an outside panel of regulators and physicians. Such panels overrule health plans’ decisions in about half of all cases.

9. And know how to do it. You must go through the internal appeals process described in tips 4 and 5 above before you can ask for an external review through the appropriate government agency in your state. To find out just how to proceed depending on where you live, visit this incredibly helpful Kaiser Family Foundation site and click on the map.

10. Contact the feds for help with self-funded plans. Many large employers provide self-funded health plans, in which the employer actually pays workers’ claims. Because such plans are not regulated by state governments, you must file complaints with the U.S. Department of Labor’s Employee Benefits Security Administration by calling (866) 444-3272 (EBSA).

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