With the advent of managed care came a cost-consciousness among health insurance companies, hospitals and physicians that will have an impact on everyone in some way. We all recognize that there have to be limits on health care so that health care costs do not spiral out of control; however, we do not want those limits to be applied to our own care in an arbitrary way, or in a way that could jeopardize our health. Managed care companies routinely scrutinize requests for treatment to determine whether the treatment is (a) a covered benefit and (b) medically necessary. Some of these treatment requests fall into gray areas, and the managed care plan can exercise its discretion. If the plan's decision is not to pay for the treatment, it will issue a coverage denial to you and/or your physician. What should you do if that happens?

Although your initial reaction to a coverage denial may be one of anger or despair, there are actually quite a few things you can do. So the first thing to remember is -- do not get discouraged! No does not necessarily mean no when you hear it from an insurance company; rather, it means probably not. It also means that the plan has shifted the burden to you and your physician to try to prove to the plan's decision-makers why they should pay for the treatment you are requesting. Many people are easily deterred by such a challenge, and they either go without treatment or they pay for it themselves. However, with the pervasiveness of managed care today, it is wise to know how to challenge critical decisions affecting your health care with which you disagree.

Eight Easy Steps For Managing Your Own AppealIf you have questions about a plan's refusal to pay for treatment, you should be very organized when you contact the plan to discuss your concerns. First, you should have a file in front of you that contains all relevant medical and insurance information, including your health benefit plan. Second, whenever possible, you should try to speak with a decision-maker, such as a department manager or medical director. Third, you should keep a written record of all communications with plan personnel, including the date and time of your conversation, the full name and title of the person with whom you spoke, and a summary of what was discussed. Fourth, send a certified confirmation letter to the plan if you want a record of certain information in your file. Fifth, submit a written complaint to the plan, so that it can go to the next level of review. Sixth, monitor the plan's response time, and make sure that your complaint is moving forward expeditiously. Seventh, resist any temptations to get angry or frustrated, and remain friendly, polite, firm and informed throughout the process. Eighth, consider whether disenrolling from the plan would be advantageous for you.

Your physician is an integral part of this process, and has a vested interest in helping you to obtain the treatment that he or she has recommended. Regardless of whether your managed care plan has refused to pay for treatment because it is not a covered benefit, or does not appear to be medically necessary, your physician is your primary advocate throughout the appeals process. Enlist your physician's help, and keep him or her informed about your efforts.

In the event that you are unable to get a denial reversed at these preliminary stages of the appeals process, you may need to appear before an appeals panel or grievance committee. Preparation for this meeting is crucial, as it constitutes your best opportunity to present the merits of your particular situation directly to the decision makers. Your physician(s) should attend, and you can also bring family members or other "witnesses." In addition, you can introduce photographs, medical literature, or other "exhibits." Your goal in this situation is to prepare a presentation that is as persuasive and compelling as possible. At a minimum, your appeal should include:

  • Your health history, including other treatments you have tried;
  • An overview of the treatment requested and its success rate; and
  • The impact on your life of treatment versus no treatment.

You should also inform the panel if the requested treatment is more cost-effective than other treatments which have been approved.

There are different organizations available to assist you with a coverage dispute. For example, the Colorado Division of Insurance has a consumer assistance program, and other states have comparable programs offered through their regulatory agencies which oversee commercial health plans. In addition, the Patient Advocacy Coalition has experienced advocates available to help you navigate your way through the appeals process. There is no magic to it -- you just have to be willing to persevere. Although the process may require a significant amount of effort on your part, it is a worthwhile endeavor to remain in control of your health care, and to challenge decisions with which you disagree.

If you would like additional information, please call the Patient Advocacy Coalition at (303) 744-7667 for a free consultation.

Note: This article does not constitute legal advice.

Patient Advocacy Coalition®I N C O R P O R A T E DMediation Specialists in Health Insurance Disputes850 E. Harvard Avenue, Suite 465Denver, Colorado 80210 USA(303) 744-7667 voice/TDD

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