Ever had a claim denied by your insurer because of something like a RAD Code 0022? If so, you're not alone.
Wading through healthcare bills is a daunting task -- and appealing them can be an impossible one. But if you think you've been overcharged or that a claim has been wrongfully denied, there's no reason to take it lying down. You might want to call in reinforcements, though. "The healthcare system is so complex it is almost impossible for a layperson to navigate through some of the stuff," said Lynne Randolph, deputy director of communications at the California Department of Managed Health Care. "I think it's extremely valuable for consumers to have an advocate on their side."
Check first with your provider or insurer to see if the problem can be resolved. If it can't, a wide range of groups -- state agencies, nonprofits, consumer advocates -- can help explain your policy or help you file a complaint.
If you think an insurer should pay a bill that was denied, you can file a complaint with the insurance company. Doing so immediately prevents the account from being sent to the collections department until the insurer makes a decision, typically within 30 days, and gives consumers time to deal with the situation, said Jessica Rothhaar, medical debt program manager at Health Access California, a statewide advocacy group.
On its website, Health Access offers details on navigating the insurance system. They include checking with the doctor to make sure the insurance company was billed in the first place, calling the insurer for an explanation of why the bill was not paid and, if neither of those steps work, filing a complaint. You can find out how to file a complaint, or grievance, by looking in your insurance documents or by calling your insurer. More detailed information can be found at hospitalbillhelp.org, a service of Health Access and other consumer groups.
Be sure to keep copies of all documentation and related correspondence, including copies of bills, canceled checks and denial letters. Write down the name and phone number of anyone you speak with at the insurance agency. This can help the complaint process go more smoothly.
The specific way to appeal an insurance denial differs depending upon the kind of insurance plan and the insurer.
Almost 20 million Californians are covered under health maintenance organization (HMO) plans, Randolph said. The California Department of Managed Health Care, which regulates the state's HMO plans and functions as policy group and consumer advocate, helps resolve complaints against these insurers.
The department's help center is staffed by attorneys and nurses who can answer questions about health plans or the complaint process, but the staff also assists simply by helping you get through to the right person at the insurance company. Sometimes the staff will set up a three-way call with you, an attorney (or nurse) and the insurer to work together to try to resolve the issue informally.
If the agency's staff cannot help resolve the issue, you can file a complaint with the department. A one-page form with your information goes to one of the department's attorneys, who has 30 days to resolve the dispute. In an emergency situation, the attorney deals with the issue within 72 hours.
If a complaint is still denied, you can request an independent medical review, in which a panel of doctors familiar with the condition looks at the case. The doctors review relevant medical data and render a decision that the health plan and consumer must follow. Randolph said consumers have a success rate of less than 50% when the complaint goes to a review board, but when they are successful, the process is worth the effort.
"With state departments, we have the force of the law behind us," she said. "If they [insurers] are not following the law, we have strong enforcement units."
The California Department of Insurance has regulatory authority over preferred-provider organizations (PPOs), which provide health insurance for approximately 6 million Californians. The department regulates licensing, marketing and policy administration. It, too, receives numerous complaints dealing with coverage, said Darrel Ng, senior press secretary for the department.
The consumer assistance process is similar to that of the Department of Managed Health Care. You can contact the department's call center for help understanding bills and for answers on what should be paid for under your policy.
"We as a regulator contact them [insurers] to make sure they have fulfilled their contract with the covered person," Ng said. "If it should be paid for, we will contact the insurance company and give them our point of view. Generally at that point, the problem will be solved."