You need heart surgery, and a university hospital in your state has a renowned cardiology center – but that hospital is out of network. Or you’re hospitalized for a chronic lung condition and you want a second opinion from a pulmonology center that handles challenging cases – but your insurer denies a transfer.

Should you take “No” for an answer and stay put, or pay out of pocket? Before you do, you have the right to appeal an insurance denial, and while there are no guarantees, experts suggest how to improve your odds of success.

Be Aware of Appeal Options

If a simple administrative error is the reason for a denial, like an incorrect medical billing code, you could clear up the problem with a single phone call to your health care provider or insurance company, according to the National Association of Insurance Commissioners. That’s the best-case scenario. With private insurance, two basic levels of appeal exist, the NAIC explains: an internal appeal administered by the insurance company, and a next-level appeal by an independent third party.

A Medicare appeal is a five-level process. “If you do level one of the appeal and they approve you, you’re good to go,” says Dr. Tanya Feke, author of “Medicare Essentials: A Physician Insider Explains the Fine Print.” If that doesn’t work, she says, you can move on to the next phase. The first two appeal levels involve health reviews of your chart. Next, your request would go to an appeals council, followed by a local court. Level five is most formidable – taking your appeal to a federal district court. “After five phases, that’s as far as you can go,” Feke says. At that point, she says, you’re liable to pay on your own.

Make ‘Medical Necessity’ Case

“The general rule is, if you are covered by a health plan that either restricts covered benefits to providers or only provides the maximum coverage if you stay in network, then you need to be mindful of that,” says Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “And recognize in most cases, if you stray out of network, you will be penalized.”

You can appeal in certain circumstances, Pollitz says. For instance, you might need surgery that can’t be scheduled with an in-network hospital in time. You could require an intricate operation, like complex vascular surgery that’s beyond your local facility’s capabilities. Or you might benefit from care in a specialized rehab unit. Basically, you have a medical necessity that your network can’t provide.

To get any of this treatment approved – first, you have to ask. “You have to say to your plan, ‘I want to go out of network and get covered as though I was in the network, and this is my reason why,'” Pollitz says. “And then you have to give them a chance to agree.” If they disagree, then you can appeal it.

When you get a denial notice from your insurer, you might be tempted to tear it to shreds. But don’t. It’s important to preserve a paper trail – plus, that letter provides need-to-know instructions for an appeal.

Keeping medical and insurance documentation in order is a must when you’re questioning a coverage denial. And keep detailed records of conversations with insurance company staff – make sure to include dates and phone numbers, and take names. Collect all your evidence to support medical necessity, including prescriptions, X-rays, lab reports, referrals and discharge summaries from hospital records. Your health plan’s website might even provide supporting material within its policy and treatment guidelines.

The insurance company could have its own appeal form, or you may have to write a letter. When submitting an appeal request, give concrete reasons why you’re asking for a certain service or provider. It’s important to make yourself clear, Feke says: “Being vague is just going to make the process much more difficult and slow.”

If a scientific study shows that a specialized treatment is more effective for your condition, “Work with your doctors to get that study to your insurance,” suggests Dr. Otis Brawley​, chief medical officer for the American Cancer Society. He says he’s never seen an insurance company refuse to pay when patients can demonstrate that a good clinical trial, published in a peer-reviewed journal, proves the therapy they want is better in their case.

Enlisting your doctor’s support can help in several ways. For instance, getting approval for lung disease care in a special facility is more likely if the insurance company acknowledges a certain treatment is not available locally, says Dr. Albert Rizzo,​ senior medical advisor for the American Lung Association.

“That may require a peer-to-peer discussion with your local pulmonologist and the medical director of the particular insurance company,” Rizzo says. As long as a requested treatment is not considered experimental, he says, in-network requirements could often be waived when a proven therapy is not otherwise available. The patient’s pulmonary specialist would put the medical records together, he says, and send them to the center of choice, along with a letter of introduction. 

If you have questions about the appeals process, you can contact your state insurance department. It might also be worth reaching out to your attorney general’s office, Pollitz says. “Sometimes your state AG will just help people navigate this process, because it can be a little intimidating,” she says. “Typically if you’re in a situation where you’re asking for this kind o
f consideration – you’re probably kind of sick.” Which, she points out, can make it difficult to find the time or wherewithal to advocate for yourself.

When you receive a coverage denial, the letter should include information on consumer assistance programs in your state. “CAPs are essentially a system of ombudsman systems for consumers, established under the Affordable Care Act,” Pollitz explains. But there’s a caveat – because these programs aren’t currently funded, they may not be operating under full power, she says.

You can call Medicare directly for more information on appeals at 800-MEDICARE (1-800-633-4227).


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