Why Appealing Your Insurance-Claim Denial Could Pay Off
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Access to affordable credit helps me pay my employees, but I don't really need it. Inflation is killing me. But who cares? Big retailers are making record profits. That's why we support the Durbin Marshall credit card bill. See? Banks and credit unions help small businesses make payroll. This bill would cut the vital resources they need. While increasing megastore profits. They deserve it, don't they? Tell Congress, stop the Durbin Marshall money grab for corporate megastores. Paid for by the Electronic Payments Coalition.
Here's your Money Briefing for Thursday, February 13th. I'm Mariana Aspuru for The Wall Street Journal.
How common are insurance claim denials and who actually appeals them?
Appealing a medical claim can be an overwhelming process involving complex paperwork, obtaining letters from doctors, and spending hours on the phone, often during one of the most difficult times in a person's life. However, studies show that up to three quarters of claim appeals are granted.
It might have been your doctor put in the wrong code or said that they were going to get it from an out-of-network pharmacy, but it turned out that you could have gotten it in an in-network pharmacy, right? There are a lot of things that sometimes are not actually huge barriers for the insurer.
We'll talk with Wall Street Journal reporter Julie Warnow about how some patients have appealed and won. That's after the break.
Access to affordable credit helps me pay my employees, but I don't really need it. Infliction is killing me. But who cares? Big retailers are making record profits. That's why we support the Durbin Marshall credit card bill. See? Banks and credit unions help small businesses make payroll. This bill would cut the vital resources they need. While increasing megastore profits. They deserve it, don't they? Tell Congress, stop the Durbin Marshall money grab for corporate megastores. Paid for by the Electronic Payments Coalition.
Health insurers deny around 850 million claims per year, according to health policy nonprofit KFF. Less than 1% appeal, but a large number of patients who do are successful. Wall Street Journal reporter Julie Warnow joins me. Julie, what are some of the reasons why a health insurance company will deny someone's claim?
Health insurance companies might look at someone's claim and say, well, there are some things that are cheaper that they needed to try first, right? So that's often a reason. Sometimes they say that they don't actually think that the diagnosis is correct or that the treatment is appropriate for the patient. And to make these decisions, they're relying on often their own policies, which are based in lots of studies and research that they've developed for pretty much any disease you can think of.
Walk me through the steps of filing an appeal.
If you look at any denial that you get and you read past the part that's going to upset you, which is, hey, we're not paying for this. You have a couple of choices. First, you could ask your doctor to appeal it. If you rely on your doctor to be the one to do this appeal process, which I think most people do. You might be surprised to learn that you have better luck when you do it yourself. And one of the reasons is you've got very busy doctors. They've got somebody on staff who's responsible for this. And it might take a little while before they're able to send the appeal over. Or it's possible that they don't know your child or your loved one or your particular situation as well as you think they do.
Second, you could appeal it yourself. First thing you want to do is make sure you actually get the denial letter. Read through and see if it tells you what to do to appeal it and then do that yourself. Or if you need help, ask your doctor for help. or there are outside groups that you can actually pay to do this for you. If you get another denial, you can do another what they call second appeal, which escalates it to a higher level within the insurance company. And then if you get another denial, in pretty much every state, there's an outside review agency is supposed to act as like the watchdog for the insurance company, you can appeal to them.
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