Suppose that your health insurer completely or partially denies payment for services that you already received. You're stuck with a big medical bill to pay out-of-pocket.
Or maybe the insurer refuses to authorize payment for services that your doctor regards as medically necessary. You're stuck with no treatment, a treatment the doctor regards as second-best, or shelling out hundreds or thousands of dollars.
What's a consumer to do in cases like these?
Unfortunately enough, they occur all-too-frequently in today's era of for-profit, bottom-line medicine. Health insurance companies may be unique in the business world in their constant attempts to provide customers less of their only service. That's payment of medical bills.
The worst possible approach is to accept the insurer's "no" as final.
Most health insurance claims are processed and paid without problems. But mistakes do occur. Some denials occur because the insurer got incomplete or inaccurate information from the physician or health-care provider.
Others result from today's system in which clerks make the first decision on paying claims and authorizing services. They may not be fully aware of the medical details of a claim.
When the insurer says "no," consider filing an appeal.
Surprisingly, only a handful of consumers appeal denied claims. One study of Medicare claims, for instance, found that consumers appealed only 2 percent of denied claims. Yet 75 percent of those appeals were successful.
Each insurance company has different procedures that customers must follow to appeal a denial. Procedures may be spelled out in the denial notice. If not, insurers must provide customers written material explaining how to file an appeal.
Medicare beneficiaries can get detailed information about appeals and grievances, including a booklet on the topic, by telephone or from the Internet. The toll-free telephone number is 1-800-633-4227. At the Medicare Internet site (www.medicare.gov), consumers can download and print out the information. Medicaid recipients can get information from their state Medicaid agency, or by searching for "appeals" on the Internet site of the federal agency responsible for Medicaid (www.hcfa.gov/medicaid.)
Individuals covered through an employer can get information - and often assistance in filing the appeal - from the company or union insurance plan administrator.
The appeal may require a brief statement explaining why you want a review of the insurer's decision and a letter from your health-care professional with more information about your medical condition.
Appeals usually must be filed within a specific period of time; so don't delay.
Commercial firms usually called "insurance appeal and recovery services" are another option for dealing with a "no" from your insurer.
For a fee, these companies review all the documents related to the denial. These include your insurance contract, medical records, denial letters, previous appeals, and state laws. The reviews are done by experts in determining whether an insurer was justified in denying services or payment.
The companies usually charge a nonrefundable "review fee" to decide if an appeal is justified, and a nonrefundable "appeal fee" if they file an appeal. If the appeal is successful, they take a percentage of amount recovered.
One company, for instance, charges $60 to review a case, $275 to appeal, and takes 25 percent of the money recovered from the insurer. Obviously, it makes sense to use free appeal mechanisms first, and turn to commercial firms only when large sums are involved.
Michael Woods is the Blade's science editor. Email him at firstname.lastname@example.org.