It's the last thing anyone wants - getting into a quarrel with a health insurer. You feel poorly matched up, and nothing stops them from taking all the time in the world. However, a report by the Government Accountability Office has found that when people dig their heels in and go ahead fighting for their insurance claims anyway, half the time, they win. They actually win against a behemoth of a health insurer that would like nothing better than to try to turn any little thing into a war of attrition. They found that in most cases, denials don't come from any basic disagreements over what medical treatment is to be allowed and what is not. Most of the time, the problem has something to do with some confusing billing or eligibility problem.
For some reason (Gee, wonder what that could be), health insurance companies never tell their customers that they can appeal any denial. It's up to customers in their confusion and fear, to figure it out for themselves. One of the most common reasons insurers deny insurance claims is for the reason that a patient hasn't obtained prior authorization for some kind of treatment. It's easy to appeal, and ask to be supplied authorization retroactively. Most the time, they grant it if you ask through an appeal. If you ask on the phone like a human being would, they won't give you the time of day.
At least, the law now requires that health insurance companies tell every customer that when they are denied a claim, they can always appeal it internally or ask for an independent review.
Have you ever had trouble with insurance claims that were termed experimental or investigational? Most of the time, a denial for this reason only means that they've made a mistake with their unnecessarily complex system. Everything for instance is categorized according to a code. Every treatment, test or investigation is to correspond to the requirements stated in one kind of code or another. Sometimes, there are multiple codes to match things to. Moreover, each type of treatment comes with a different code depending on what age a patient is. If for instance, there is a blood test that you need, and the clerk at the insurance company makes the mistake of putting down the code number for a blood test for a 15-year-old girl instead of for 25-year-old you, the system blames you for trying to get treated for something you are not eligible for.
Sometimes, problems with insurance claims that you take up with your insurance company can actually take in excess of three months to have resolved. In these cases, usually, phone calls won't give you the kind of results you're looking for. In a case such as this one, all you have to do is to drive to the hospital and talk to the people in charge. Sooner or later, they always back down.
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