Appealing Insurance Claim Denials


How Did We Get Here?

Example 1

Your child has autism. Your child also gets sick, a lot. You take him to the doctor, again, to see what they can do to get him healthier. The doctor orders blood work that shows your child has a very weak immune system and multiple food allergies. The doctor refers you to an immunologist but codes the superbill with 299.0 (autism). The insurance company denies the specialist visit and all treatment because autism in (in their eyes) untreatable. This is an example of denial due to improper coding.

Solution: Call the doctor back and ask that the superbill be recoded to reflect WHY he needs the immunologist – due to immune deficiencies and allergies and REMOVE all reference to autism, as it’s not relevant to this case. This is one of the quickest routes to medical denials you will find. Make sure you never leave the doctor’s office with a superbill that says “autism” unless you are treating with psychotropic drugs. Those are the only approved “treatments” for autism according to the insurance industry.

Example 2

Your child has autism. Your child also lost the ability to speak when he regressed into autism. Your doctor writes a script for Speech therapy. Your insurance company says they don’t cover speech for autism. Period.

Solution: Why did your child stop speaking? Did he (like most kids I know) have recurrent ear infections? If so, bill it under that. Does he have verbal apraxia? If so, bill it under that, and so on.

Example 3

Your child has autism and your insurance company tells you they cover 60 visits a year of speech therapy. Your pediatrician and speech therapist recommend therapy 5 days a week (intense therapy while the child is very young will likely reap bigger dividends long term) but that would mean 260 visits in the year, not 60.

Solution: Appeal! Ask your insurance company what their appeal procedure is and if there are any special forms they want you to use. Get your doctor to write a letter of medical necessity for the extra therapy sessions. Ask the speech therapist to write a letter of medical necessity for the extra therapy sessions. Write a cover letter that explains why you need it, and don’t be afraid to pull at their heartstrings! You are passionate about your child getting better, let it show!

Example 4

All of the in-network providers reject you – they aren’t taking new patients, don’t treat pediatrics, won’t treat a child with autism or if the insurance company doesn’t have anyone contracted to provide a particular therapy.

Solution: Appeal! You can appeal for them to let you go to an out-of-network provider - but they must reimburse you at in-network rates and maximums.  They can create a contract-for-one if need be.

Example 5

The insurance company tells you that your school should provide it so go to them.

Solution: This is illegal. Appeal. A letter of medical necessity should do the job.

What To Do When You Get a Denial of Coverage

So things are swimming along and your EOB (Explanation of Benefits) comes that says DENIED!  Here’s what you do.

The best way to fight a denial is to never get one. To that end, take the steps on How to Start Working with Your Insurance Company. Knowledge is power and if you can head off a mistake by knowing what is allowed and what isn’t, it will save you in the long run.

  • Get your ducks in a row. Gather all the information you will need for the appeal.
    • Your health insurance plan
    • The written denial
    • Doctor’s bills
    • Doctor’s referrals
    • Medical records
    • Physician’s letter of medical necessity
    • Study references that show the treatment works
    • Call your state’s Department of Insurance and get a copy of the “Standards for Health Insurance”. Find out if you insurance plan is in compliance with the law.
      • Under your state’s law, is the treatment covered/included?
  • Call the insurance company and confirm the denial.
    • Ask to verify the denial and get reasoning.
    • Ask to verify the diagnosis (ask what ICD9s were submitted).
    • Ask to verify the treatment (ask what CPTs were submitted).
    • Take good notes. Get names, phone numbers, extensions, etc.
  • File a formal appeal.
    • Learn and follow the insurance company’s guideline and process.
    • Use the proper forms.
    • Make sure you don’t miss deadlines.
    • Ask for a formal review of your appeal, preferably by someone in the department dealing with the disorder (i.e. cardiologist for a heart-related treatment)
    • What your appeal letter should include:
      • Your contact information
      • Your insurance information
      • Dates of service
      • Description of service
      • Doctor referrals
      • References to benefits packages that support covering the service
      • Supporting information to why the service should be covered
      • If the treatment the standard of care for this diagnosis
      • If the treatment is covered by Medicare
      • When you send your letter, send it certified and send a copy to your physician, your employer, your state’s Department of Insurance.
    • NEVER SEND ORIGINALS, ONLY PHOTOCOPIES. Parents often report back that their insurance company “lost” their submittals, again.
  • File an appeal with your state Department of Insurance
    • Contact the Department of Insurance in your state and ask them for a copy of the state’s standards for health insurance.
    • Ask them about ERISA (Employee Retirement Income Security Act) pre-emption.

State Department of Insurance Appeal Resources

Consumer Reports

Consumers Union

National Association of Insurance Commissioners

Directory of Insurance Regulators by State

Consumer Action - Federal Consumer Information Center


Some Tips About State Laws

Understanding the State Insurance Process

  • States establish Licensing and/or Certification procedures for Care providers
  • State Medical Boards oversee the Discipline procedures for those who violate law or conduct malpractice.
  • States implement Medicaid and waiver Programs, based on Federal Regulations.
  • This federal law supersedes state laws regarding coverage in Employee Benefit plans.
  • Cases brought against an HMO must go through federal court system
  • Must prove that the Company acted outside Plan defined coverage.
  • States can decide what are approved services, or inclusions in insurance policies written in that state.
    • This is done using many facets of information:
      • Published Peer Reviewed Studies
      • Medical/Psychological/Dental Association acceptance of practice
      • FDA approval for Drugs
      • public or professional opinion or moral stance on a subject
    • What determines acceptable procedures?
      • Published Peer Review studies are as credible as the Publication, Journal of American Medical Association, for example, is considered a highly credible publication.
      • Most Insurance Companies have an in house review panel of Medical Procedures
      • Whether Inclusion of procedure in the CPT-4 or HCPCS for diagnosis or suspected diagnosis.