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How to Win a Medical Insurance Appeal

The lowdown...
  • Look for a simple fix first, such as the claim being denied to errors in spelling or numbers
  • Find out the exact reason for the medical claim denial
  • Discover what treatments and services your insurer typically approves, or denies and avoid any that are not FDA approved
  • Put together scientific information that backs the treatment option that is being denied
  • Have your doctor send a letter to defend the choice that is being denied

Facing a medical claim denial and filing an appeal is not as difficult as it might seem. Putting together the right information will go a long way towards proving your side of the case. Accurate facts and the backing of the treatment professional are often all it takes to change the outcome in your favor.

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Look for the Simple Fix


The denial of an insurance claim can be caused by something as simple as a misspelled name, incorrect address, or a wrong numeric code for a procedure. These simple problems can be cleared up with a phone call.

Not every denial for treatment is based on the proposed treatment method, cost, or debate about effectiveness. Always look for the simple fixes first. This will save a lot of wasted time and feelings of frustration.

Why was the claim denied?


If your medical claim is denied, the insurance company will send a letter that states the reasons for the decision. This is a valuable piece of paper that you want to go over thoroughly, ensuring you have a grasp on exactly why the denial happened. You can better plan a defense to prepare an appeal by absorbing and understanding why the claim was denied.

Take the letter to a healthcare advocate if you are unclear on the language used as to why your claim was denied. It is difficult to fix the situation if you cannot understand what the letter is saying. Look through your policy papers and find an “Evidence of Coverage” page. This will clue you in to the language of the company, which should make the denial letter more understandable.

Understand the Treatments and Services the Insurer Typically Approves

Do a little checking and see what services and treatments the insurer typically allows and which ones they have problems with. There are some treatments, especially for serious diseases like cancer, that most insurance companies do not like to pay for. They are considered expensive and at times offer no real guarantee of the patient getting well again.

You can typically find a little information online about insurers that have denied certain types of treatments and procedures and the given reasons why.

It will help you know ahead of time whether you have a potential battle on your hands if that is the treatment option preferred by your treating physician.

Avoid Treatments that are not FDA Approved


Treatments that are not FDA approved will be denied. There is no way of knowing if they are safe, or effective. Experimental procedures without good science and positive results will hardly ever be approved. It is an uphill battle that you most likely will not win. Avoid these treatments unless you are able to self-pay, or find another source of funding.

New forms of cancer treatments are the most common and likely of medical procedures to be denied. The insurance company does not enjoy seeing people suffering from a serious illness, but there ha to be real numbers behind the treatment that show it is worth the expenditure.

Do Your Research to Defend Your Treatment Choice


Utilize the help of medical journals to research good facts and figures about the treatment you wish to get and have had your claim denied. Ask your doctor to help with any of the information you do not understand. If you formulate your argument well, your appeal might work. Use studies that contain random subjects and offer an objective view when it comes to the results.

Everything you are willing to do in order to bolster your case and make them feel comfortable about backing treatments and procedures that are more costly than others is helpful.

Positive facts and figures can show the reality of the beneficial nature of some of the more untried methods in treating illnesses. There are times you stand a decent chance of changing their minds and having a denial overturned.

Incorporate the Help of Your Doctor


Your doctor should be willing to help back up the need for you to receive the disputed treatment or medical service. A well-stated letter can go a long way towards reversing a medical claim denial. Any positive input you can get from medical professionals with expertise in the field will prove helpful and can quickly change the outcome.

Winning an appeal is as simple as putting forth the right information demonstrating that the best decision is one that leads to a positive resolution of a tough medical problem.

Consult with health insurance experts before launching an appeal of a medical claim dispute. Find out the steps you need to take to get the needed medical services right away!

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