Denied care? Know your options

Dear Kyle:

Thanks for your time on the phone regarding my claim.

When you hear that your insurance denied something your doctor recommended, your first reaction is fear. You start wondering whether you can afford the treatment, whether you should wait, and what happens if you do nothing. Most people don't know that a denial can often be challenged, and I appreciate your education on this!

—Joe B.

Joe, it was my pleasure and my job. Let's break this down for our readers.

For Californians waiting for an MRI, prescription, surgery or other treatment, an insurance denial can feel like the end of the conversation.

That does not have to be the case.

Denials may involve prior authorization, when an insurer requires approval before treatment, or a claim denied after care has already been provided. Either way, you do have options.

Here is what to do when the answer from your health plan is "no."

Get the denial in writing.

Ask the insurer to explain why the service was denied and what information it used to make the decision. Keep the denial letter, explanation of benefits, medical records and prior-authorization paperwork.

Call your doctor.

Ask the doctor's office to review the denial and provide supporting medical records or documentation. In some cases, the issue may be missing information rather than a final determination about the treatment.

File an appeal or grievance with your health plan.

Use the member-services number on your insurance card and ask specifically how to file a grievance or appeal. Put the request in writing when possible and keep a copy.

If waiting could seriously threaten your health, tell the plan that the matter is urgent and ask for an expedited review. California's Department of Managed Health Care says qualifying urgent cases can receive a decision within three days.

If the denial stands, consider an Independent Medical Review.

For qualifying cases, an independent medical professional can review whether treatment was medically necessary. The process is available through the California Department of Managed Health Care (DMHC) for plans it regulates and through the California Department of Insurance for qualifying insurance policies.

For DMHC-regulated plans, consumers generally must first use the health plan's grievance process. If the problem remains unresolved after 30 days, or the consumer disagrees with the plan's decision, the consumer can contact the DMHC Help Center. Urgent cases can receive immediate assistance.

The DMHC Help Center can be reached at 1-888-466-2219 and provides assistance at no cost. The key is not to assume that the first "no" is the final answer.

For patients and families already dealing with illness, the insurance appeal process can feel like another obstacle. But keeping the paperwork, involving the doctor's office and knowing where to escalate a denial can turn a confusing letter into a series of concrete steps.

The question after an insurance denial shouldn't simply be, "Why did they say no?"

It should also be: "What can I do next?"

Contact Kyle Iverson at KIverson@SchretteInsuranceServices.com.

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