Denials and Appeals

How do I appeal a denied claim in an MCO?

First, understand that cancer is an expensive disease, and plans do not want to return money that they have denied. Focus on the following issues:

Check to ascertain whether your doctor is filing an appeal

Doctors who take assignment of private benefits generally do not like to be out the money they would have been paid if the insurance company had approved your claim (if the appeal is about billed services). But no matter what the appeal is about, unless the grievance includes your doctor, you and your doctor should be the appeal team. Your doctor should be the captain of the clinical team, and you or your caregiver should try to figure out the process within your insurance company to get your grievance or appeal heard or seen.

Understand what type of coverage you have

• Employer-sponsored coverage: Most people with private insurance are covered by an employer-sponsored health plan. An employer-sponsored health plan is one that you or a family member enrolls in through work and to which the employer makes a contribution for the coverage. If you have this insurance, you have a right under federal regulations to appeal disagreements about benefits through the plan’s internal appeals process. So, if you are enrolled in an employer-sponsored health plan that is not self-insured, you usually have rights under federal and state laws if you have a dispute with your health plan. In fact, you can call or write the Commissioner or Director of Insurance in your state and complain.
  
• Self-funded plans: Whether you have additional rights under state law will depend on whether the health plan is insured or self-funded. This is because of a federal law called the Employee Retirement Income Security Act, or ERISA. Employer-sponsored health plans that are self-funded get a pass on state insurance laws. A health plan is “self-funded” if the employer pays doctors and hospitals directly.
  
  It can be a challenge for you to find out if your health plan is insured or self-funded because no one wants to give you the information. You may think your coverage is from a health insurance company, such as Blue Shield, but if you work for a large employer, those insurance companies may be out of the payment picture. Instead, they may simply process the claims as a “third-party administrator” for your employer’s self-funded plan. To find out whether your employer-sponsored plan is self-funded, first ask the person who administers the benefits where you work. If you can’t find out from your employer or the summary plan description, you can contact the U.S. Department of Labor’s regional office nearest to you.
  
• Individually purchased coverage: If you purchased insurance directly from a health plan (your employer does not provide coverage or contribute to its cost) or a broker, you need to ask your broker or look at the laws of your state to determine if you have the right to appeal a dispute over benefits using the plan’s internal procedures or your state’s external review organization. Most states have laws that provide for internal and external review of disputes over coverage that you purchase as an individual. Plus, many well-established companies, such as Aetna and CIGNA, are subject to appeal or external review.

Prepare an initial appeal

Again, contact your physician to see what he or she is doing about the appeal. Next, contact your employee benefits manager or insurance agent to see if he or she can help. If not, your next step is to contact the plan’s customer relations department. Although many disagreements will be solved at this level, this may be just the first step in a lengthy process. Here are some other steps:

• Start your recordkeeping immediately. If you have your patient health record, you have your clinical information.
  
• Next, you need to keep records of the process. Assemble a file containing any paperwork you already have (such as bills or physician information), and keep a log of every telephone call you make to the plan. Always ask for the name and job title of the person you are talking to.
  
• Before hanging up, find out what will happen next and when it will happen. If the representative says he or she will get back to you, ask when you can reasonably expect a reply.
  
• Mark that date in your notes and on your calendar. If you don’t hear from the plan by that date, it’s time for another phone call.
  
• If you still do not hear something for more than 15 days, call again and ask to speak to a supervisor.

Prepare a formal appeal

If your attempts to deal with the health plan by phone are not successful, you will have to file a formal appeal. This is a paper chase, to be sure! Health plan procedures vary, but all will require that all case details are submitted in writing. Some plans allow you to initiate the appeal on the telephone, but then will ask you to complete a form and submit it before your case can be heard by anyone. If your plan does not provide an appeal form, consult your summary plan description or the evidence of coverage for a description of the appeal process. Look for what information they need in order to hear your case. Be sure to provide answers to all questions. Expect to provide the following information in your written complaint:

• Your name, address, and telephone number
• Your insurance plan number or group code and member identification number or Social Security number
• Your provider’s name
• Description of the service or procedure you want to have covered
• Information supporting why the service should be covered (clinical information is best)
• Recommendations and referrals from your doctor regarding why the treatment or procedure should be covered
• References to the sections of the evidence of coverage or your insurance documents that apply to your situation.

You may have to file your grievance within a specified time period. If you do not file on time, your case will be dropped like a hot potato. For example, the health plan may say it must receive your appeal within 1 year of the date of treatment or within 60 days of the date the plan tells you it is denying your claim, whichever comes first. Employer-sponsored health plans must allow you at least 180 days to file an appeal.

Use Guerrilla Tactics

Most cancer patients win appeals. However, you may go through the formal appeal process and get turned down for a treatment that might save your life. If this is true, get active! Do not take no for an answer. Here are further measures to get your claim paid if you have exhausted all other possibilities:

• Unless your complaint is about them, make sure your oncologist or other cancer specialist is involved. They probably are involved if it is a payment issue. But make sure you are fighting as a team. If you come in with conflicting information, you may both be out of luck.
  
• If this a drug claim, do not forget the drug company: They sometimes will help with the claim. Many of them have programs that will cover the cost of the drug. If they do, you will at least not be responsible for those charges.
  
• Write a letter to the highest-level person at the department where the denial originated. The person (usually medical review) who denied your claim has a boss. Escalate your written appeal and your file.
  
• Call the insurance commissioner of your state. Gather all your records and information before you call. Be sure you can relate your case on the telephone and tell them the names of everyone that you have contacted. Usually, your doctor’s office has the phone number of the state’s insurance commissioner.
  
• Write a letter to the president of your company. CEOs do not like to hear that they are paying a fortune for insurance while cancer patients are not being covered. Do not do this unless you are quite sure of your case.
  
• Go to the press. No insurance company wants to hear on radio or TV or see in print that they denied a cancer patient a life-saving treatment. Again, make sure your case is really strong before you do this. You must be able to support that the insurance company was unreasonable. If you cannot do this, you will look like a public nuisance.