Just about anyone who has phoned a health insurance company will tell you it can be frustrating. There are often long wait times, and, particularly in the beginning, it can be challenging to explain your question and understand the answer. As you’ve probably become aware, health insurance has a language of its own.
Effective communication with your health insurance company is crucial. Learning more about what your policy does and does not cover will help you better work with your insurer to make sure you receive all the benefits and coverage to which you are entitled. You will also be better prepared to deal with any questions or disputes you may encounter.
Who can help?
- To find out more about your coverage, you can speak with:
- The employee benefits manager or human resources personnel at your place of employment (or your loved one’s place of employment)
- The insurer’s customer service department
- A case manager assigned by your health insurance company
- Your cancer care team social worker
- The hospital financial counselor
- Each state has a consumer advocacy office that regulates or oversees private insurance companies and plans that operate in the state. They also help consumers with problems or questions about an insurer. To find your local consumer advocacy office, you can search online, contact a social worker at your cancer center or contact your state Attorney General’s office
- The Department of Labor, if you are insured with a federal health plan such as Medicare
As you develop a relationship and work with your health insurance company, it is helpful to remember that in theory you both have the same goal — to get you the best, most cost-effective care possible. Keeping this in mind can help you frame your conversations.
Appealing Insurance Denials
Unfortunately, in today’s health care system it is not unusual for claims to be denied or for insurers to say they will not cover a test, procedure, or service that your doctor ordered. If you have established a working relationship with a customer service representative or insurance case manager, it will be easier to manage this situation. Regardless, you can appeal your health insurance company’s decision, and you may be able to get the decision overturned.
If you want to appeal a decision, you may want to first check with your health care team to see if there is someone on staff who can help you. This is particularly true if an insurance company is refusing to give prior authorization for a service. Your treatment facility may have someone who is familiar with the appeals process and knows individuals at your insurance company. If the appeal is for coverage of a specific medication, some manufacturers may also be able to help you with your appeal.
If you choose to file the appeal yourself, remember that while you may feel angry that the insurance company has denied one of your claims, courtesy and a cool head will increase your chances of success. It is perfectly normal to be frustrated, irritated, or angry that a claim was denied. However, how you share that frustration and anger may affect the success of your appeal.
Before you call the insurance company, you may want to role play this conversation with someone else. Ask someone to act as the insurance company representative while you play yourself. This will give you an opportunity to express your frustrations in a safe environment and further refine your approach to the situation. Taking a step back from an upsetting situation with the insurance company can benefit you. Yelling at the insurance company’s customer service representative or medical director is not likely to be effective.
If your appeal is denied you still have options. You can re-submit the claim until you exhaust the insurance company’s internal appeals process. You can also request help from the consumer services division of your state’s insurance agency or the Department of Labor if you are insured under a federal policy. There are also nonprofit organizations that can provide detailed information about insurance appeals such as the Patient Advocate Foundation and the Cancer Legal Resource Center.