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Ten Tips

If your medical claim is unfairly denied

© St. Petersburg Times
published June 23, 2002

A recent report by the Kaiser Family Foundation revealed that almost half of all consumers say they have experienced problems with their health plans. The most common problems involve denials of coverage or care. If you're grappling with such an issue, it's important that you understand your rights and know how to get more information from your health plan. Consider these tips.

1. BEGIN WITH YOUR PLAN'S CUSTOMER SERVICE DEPARTMENT. Call and ask why your claim was denied or not paid in full. It might have been due to an administrative error. Have all your paperwork in front of you when you make the call, and keep a careful record of all correspondence with the insurer.

2. IF THAT DOESN'T WORK, you have the right to request a formal review by your insurer. In most cases, you must file the request within 60 days of receiving the original explanation of benefits. Make your request in writing, and send it via certified mail.

3. REVIEW YOUR DOCUMENTS CAREFULLY. If you launch such a formal review, you'll be given access to all the documentation used to determine your benefits. Don't be surprised if you discover an error that could change a denial to full payment.

4. QUESTION RATES THAT SEEM UNREASONABLE. Most health plans say their fee schedules are not subject to change, but if you know that a certain reimbursement is especially miserly, call and question it. Most insurers will investigate large discrepancies, and on occasion they will make changes.

5. FILE A COMPLAINT IF NECESSARY. If your health plan won't help you at all, you may need to alert regulators to your situation. You can file a complaint with the Florida Department of Insurance by visiting or calling 1-800-342-2762.

6. KNOW WHEN TO SEEK AN OUTSIDE REVIEW. If your insurer denies your claim on the grounds that a treatment is not medically necessary and you strongly disagree with that decision, you can request a review by an outside panel of physicians.

7. IT'S WORTH A TRY. If the outside panel overturns your health plan's decision, the company must pay for the treatment. Insurers get overruled in about half of all cases across the country.

8. TURN TO THE FEDS FOR HELP WITH SELF-FUNDED PLANS. Many large employers provide their workers with self-funded health plans, in which the employer actually pays workers' claims. Because such plans are not regulated by the state, you must file complaints with the U.S. Department of Labor's Pension and Welfare Benefits Administration by calling 1-866-275-7922.

9. FIND AN ADVOCATE. You always have the option of suing your employer, but before going that route, it might be smart to seek out help from the Agency for Health Care Administration, which is part of the Florida Department of Health and Human Services. Visit or call 1-888-419-3456.

10. AVOID PROBLEMS BY READING THE FINE PRINT. Before you make an appointment to see your doctor or specialist, bone up on your health plan's rules and clarify what your plan will and will not cover.

-- Sources: SmartMoney Magazine; CareCounsel

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