Don’t Take No for an Answer: 10 Tips for Fighting Denials
By Barbara Griswold, LMFT
(April 17, 2010)
You’ve received a denial from an insurance plan. You think, “Why bother fighting? It takes too much time, and I won’t win.” But in my experience, if you follow the tips below, your chance of overturning the denial can be quite high.
- Start with a call to Claims or Customer Service. While some errors can be quickly identified, allow at least 20 minutes for the call.
- If the denial reason was “no pre-authorization,” ask the plan to back-date one. If they will, resubmit the claim with a note including the new auth number. If they won’t, appeal.
- If the denial involves a treatment issue, put together a clinical argument for how the sessions are medically necessary, are the best type of treatment, and prevent more intensive treatment. Outline your treatment goals/plan. Review the plan’s Medical Necessity Guidelines (often in the Provider Manual, on the plan’s Web site).
- Avoid defensiveness, threats, or overly dramatic predictions of consequences if your appeal is not granted. Imagine that the plan simply needs some additional clinical information to see it your way.
- If needed, ask to speak to a supervisor (or even the plan’s Clinical or Medical Director). They have more power to make exceptions.
- If the plan requests repayment, delay payment. Call the plan (or financial recovery service) and have your intended appeal documented.
- If still unresolved, the client can ask his employer’s Benefits Manager to intervene on his behalf. Because employers pay the premium, the plan may be more responsive when the Benefits Manager calls.
- Submit an appeal. This is a written notice challenging a denial or requesting an exception to the plan’s policies. Even out-of-network providers can appeal, or if it was your error that led to the denial. A sample appeal letter can be found in my book (click here for info). Contact the plan for details about its appeal process and filing deadlines. If treatment is the issue, focus on why the treatment is the most clinically (and cost) effective. Include copies of relevant documents. Your client can write the plan and (at no charge) receive information used to review the initial claim/treatment request – this can assist in your appeal. Ask for an expedited appeal if you need immediate approval to continue necessary treatment.
- Get help. Helpful appeal resources include a non-profit patient advocate such as the Patient Advocate Foundation (800-532-5274, www.patientadvocate.org), your professional organization, or hire a professional insurance consultant (contact me for names).
- Appeal to your state’s Department of Insurance or Department of Managed Health Care. Take this step if your appeal has been denied or ignored. Your appeal has a good chance of being supported: Of the mental health Independent Medical Reviews performed by the California Department of Managed Health Care in 2007, 47% overturned the denial by the health plan.1
Remember to keep a communication log, with names, dates, and conversation details.
And don’t worry, you aren’t being codependent when you fight for your clients. Most professional therapist associations have ethical standards that require members to advocate for the care they believe will benefit clients. Assisting a client with an appeal may even be required by state law.
1 – “California Department of Managed Health Care 2007 Independent Medical Review Results by Health Plan Report Definition,” retrieved 4/17/10 from http://www.hmohelp.ca.gov/library/reports/complaint/2007.pdf.
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Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should. To purchase the book or other resources for therapists, click here. Contact Barbara at firstname.lastname@example.org to get answers to your insurance questions.
Copyright 2008-, Barbara Griswold, LMFT. No part may be reproduced without written permission of the author.