HEALTH INSURANCE
Navigating the Process – Pursuing Benefits
Health Insurance can be perceived as different things to different people:
- A comforting safety net against the possibility of a catastrophic accident or illness;
- An ever increasing family expense, often ignored until it is needed;
- A major problem when a claim is filed and what was thought to be “covered” – isn’t covered;
- A financial life saver when benefits are paid for essential medical treatment;
In reality, the truth is often a combination of all of the above. The world of health insurance and the claim process can be confusing and sometimes very frustrating. That’s why it is important know how things work and what to do when roadblocks are encountered.
This section will outline some basic information and suggestions to help you better understand the process and provide references to sources of more detailed assistance. Hopefully, this will ensure that you are positioned to achieve the best possible outcome in your particular situation.
The Problem:
- The health plan or managed care company has not approved a request for a medical procedure, a treatment plan, medication or medical equipment for you or a family member. Now what???
The Response:
Do Your Homework:
- First, you need to know whether your employer’s health plan is fully insured or self-funded. This is essential because fully insured state licensed health plans are regulated under CT state law and self funded health plans are governed by federal law (ERISA). Presently, approximately 50% of privately insured citizens are covered under each type of plan.
- Also, if you work for an employer with an out of state headquarters and its health plan contract is issued in another state, then the laws of that state will apply - not CT laws. (Unless it is a self funded plan when federal law prevails).
- Then, carefully review the content of your group or individual summary plan description (SPD). Determine exactly what is or is not covered in your specific plan and its claim filing procedures. If a medical service or drug is denied because it is not in your plan, then no amount of discussion or appeal is going to change that reality.
- Next, check with your physician’s office to inquire if they have any additional information or insight about why your claim was denied. Obtain copies of whatever documentation was submitted to the health plan for approval.
IMPORTANT: Throughout the process, document everything you do from “Day 1”. Keep notes on all calls made and include date, time, contact person, content of discussion, agreed upon action steps and expected timeframe to follow-up.
If possible, utilize e-mail and follow up each conversation with a confirming e-mail to document all that has been discussed.
Disputing the Denial – Beginning the Process / Laying the Groundwork:
- Start simple – call the health / managed care plan to speak to a representative. Ideally, this will be a team member who is assigned to routinely handle all claims from your employer or plan. The denial letter will also contain a toll free number and/or name of the individual to speak with.
- Before that first conversation occurs, get yourself into the proper frame of mind and attitude. It is extremely important to recognize that the representative:
- Is not your enemy or a person who is purposely trying to make your life difficult;
- Is doing his or her job, just as you do yours;
- Will most often react to someone more favorably when a “personal connection” is made beyond the immediate issue under discussion. Tell them a little bit about you and your family; some recent things you have done; ask how they are today or briefly touch upon some current topic.
- Will be more likely to assist you to the extent possible when addressed in a respectful, appreciative and sincere manner.
Taking this approach certainly does not, by itself, guarantee anything. However, do not underestimate the power of “being nice” in terms of how health plan personnel may view your situation. This is especially true when the involved issues are open to interpretation and/or compromise.
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- When speaking with the representative, ask if they can provide some further details or insight as to why the service has been denied. These member service representatives process thousands of claims and likewise see the results of appeal decisions rendered by the medical experts.
Therefore, directly ask the representative if there is a better or different way in which the claim can be presented to improve the chances of its acceptance upon appeal. It is possible they may offer some further insight that will be useful as you pursue the matter, especially if a good interpersonal connection has been made. If not, you are no worse off for having tried.
Formally Appealing the Benefit Denial - Internal Process
- Always initially appeal directly to your own health or managed care plan. (NOTE: Check your individual plan to determine if it provides for continuing payment of the benefits being contested while any level of the appeal process remains pending).
- The most essential component of the appeal is your own letter that clearly outlines the entire picture. Key elements of the letter should include:
- A summary of the illness and treatment received;
- A restatement of the health plan’s reason(s) for denial of the claim;
- The reason(s) you believe the benefit denial is wrong, citing any supporting facts or opinions you have obtained from your physician or other sources
NOTE: If these factors apply to your situation, be sure to cite factors such as “quality of life” and/or “medical necessity” as part of your rationale
- What you are requesting the health plan to do in response to your appeal
- A request for a complete copy of the health plan’s file on your claim
- Health plans must provide a timely response to your formal appeal based on a review of the case by a qualified physician in the involved specialty or area of care. The reviewing qualified physician may be an in-house health plan employee or a physician with an external contracted peer review service.
- Timely response is based on calendar days and is dependent on the nature of the particular claim:
- Emergency / urgent care situations require a response within 72 hours per both CT state and federal laws;
- For pre-service claims (e.g. preauthorization or decisions on medically necessary treatment), a response is to be provided no later than 30 days after appeal is filed;
- On post service claims (e.g. majority of claims), a response is mandated no later than 60 days after appeal is filed.
- If appeal is denied, you can usually request a second level of internal appeal, typically at the plan medical director level. At this level, some health plans offer the opportunity to appeal your case in person and, if able, you should do so in order to maximize your chances for a favorable outcome.
- The Office of the State Healthcare Advocate is an excellent resource for information and assistance during the appeal process and a source of much of the information outlined here. The earlier they become involved, the more help they can provide and the greater the chance for a positive outcome. In certain instances, their assistance will include attending a second level appeal hearing with you
Internal Appeal Denied - Continuing the Process via an External Appeal
- If the internal appeal process has reached an unsuccessful conclusion, you may still appeal the situation externally via the Connecticut Insurance Department for a $25 filing fee (non refundable).
- Eligibility requirements:
- Appeal must be filed no later than 60 days after receiving the written notice that all internal appeals have been denied;
- You must have been actively enrolled in the managed care plan when the service or procedure at issue was requested and it must be a service or procedure covered in the contract
- If your employer’s plan is self funded, external appeal is not available (except in the instance of a self funded government health plan, which is eligible).
- External review is also not available to individuals in either Medicare Supplement or Medicare Advantage plans.
- The Department will then refer your case to an outside independent review firm that will advise both you and the Insurance Department if it has been accepted for a full review within five (5) business days of receipt. If denied on this preliminary basis, the external appeal process is over.
- If accepted, the review firm will engage an appropriate specialist for the review and submits its recommendation to the Insurance Commissioner within thirty (30) days.
Staying the Course:
Make no mistake, the appeal process can be a long, difficult and often a frustrating experience and there is no certainty that you will prevail in the end. However, it is important to hang in there for the sake of your family and to persevere to make sure that all possible actions are taken in the fight for whatever benefits you feel are reasonably owed.
While the degree of denials that are reversed upon internal appeal varies by health plan, statistics confirm that reversals are made on between 15% to 40%+ of appealed cases. Similarly, recent experience on the external appeal process in Connecticut reflects a successful reversal rate approximately 35% of the time.
These real life results should give you confidence that you do have a “fighting chance” to successfully reverse a denial benefit upon appeal. Even if your effort ultimately fails, you can still take comfort in the knowledge that you have done everything possible to obtain the treatment you or your family member requires. Considering the stakes, can you in good conscience do anything less?
Sources of Assistance:
Office of the State Healthcare Advocate www.ct.gov/oha / www.omc.state.ct.us
Connecticut Insurance Department www.ct.gov/cid
- Click on : “A Comparison of Managed Care Organizations in Connecticut”
- Click on : “Consumer Service” then “External Appeals
U.S. Department of Labor www.dol.gov/ebsa/publications/filingbenefitsclaim.html
PDF Files:
Healthcare Plan: Know your Rights
Mental Health
Understanding your managed care plan |
