Three Tips on How To Appeal A Claim

I recently came across this great article from Dr Eric Plakun (might have moved!) about appealing medical health treatments that have been denied by insurance companies.

Sometimes when claims are denied it can be hard to know how to appeal but this article really breaks it down clearly into the 3 things you need to focus on.

1. Get others to back you up!

“Your voice and the voices of those supporting your treatment matter.”

Make sure that the client, family members and any referring clinicians and officials that can offer assistance (such as your state’s insurance review board or benefits manager) write letters explaining the client's need for treatment and challenge any specific reasons that the insurance company has given for denial.

“Whatever actions you take, fully document all interactions you have with your insurance company or the reviewing agency—including hold times, referrals to other phone numbers, and the like. Show that you have the will and the wherewithal to stand up for your rights.”

2. Use third party resources to anchor your appeal

“Research and other benchmarks to back up claims of medical necessity are helpful in the appeals process.”

Make sure that you provide research and evidence to back up your claim for this treatment. Dr Plauken cites good places to look:

1. Level of Care Utilization System (LOCUS) developed by the American Association of Community Psychiatrists.
2. The American Psychiatric Association (APA) Clinical Practice Guidelines
3. Current peer-reviewed research 

“Citing resources like these can help in building a case for treatment that you and your treating clinician believe to be medically necessary.”

3. Invoke the parity law

“The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that the quantitative (e.g., number of office visits, or inpatient days) and non-quantitative (e.g., hurdles like prior authorization or concurrent review) limits applied to access to mental health care be comparable to those applied to medical coverage.

For example, if a health insurance company says someone with a mental health issue cannot receive treatment unless he stops drinking, but continues to cover treatment for someone with diabetes who is not following his diet, the policy is likely out of compliance with the parity law.”

Dr Plakun also suggests referencing Judge Joseph Spero’s verdict in the Wit v. UBH/Optum case. To find out more about that and to read the article in full click here. 

There is also this amazing guide from the Kennedy Forum.