Ever had a claim denied by your insurer because of something like a RAD Code 0022? If so, you're not alone.
Wading through healthcare bills is a daunting task -- and appealing them can be an impossible one. But if you think you've been overcharged or that a claim has been wrongfully denied, there's no reason to take it lying down. You might want to call in reinforcements, though. "The healthcare system is so complex it is almost impossible for a layperson to navigate through some of the stuff," said Lynne Randolph, deputy director of communications at the California Department of Managed Health Care. "I think it's extremely valuable for consumers to have an advocate on their side."
Check first with your provider or insurer to see if the problem can be resolved. If it can't, a wide range of groups -- state agencies, nonprofits, consumer advocates -- can help explain your policy or help you file a complaint.
If you think an insurer should pay a bill that was denied, you can file a complaint with the insurance company. Doing so immediately prevents the account from being sent to the collections department until the insurer makes a decision, typically within 30 days, and gives consumers time to deal with the situation, said Jessica Rothhaar, medical debt program manager at Health Access California, a statewide advocacy group.
On its website, Health Access offers details on navigating the insurance system. They include checking with the doctor to make sure the insurance company was billed in the first place, calling the insurer for an explanation of why the bill was not paid and, if neither of those steps work, filing a complaint. You can find out how to file a complaint, or grievance, by looking in your insurance documents or by calling your insurer. More detailed information can be found at hospitalbillhelp.org, a service of Health Access and other consumer groups.
Be sure to keep copies of all documentation and related correspondence, including copies of bills, canceled checks and denial letters. Write down the name and phone number of anyone you speak with at the insurance agency. This can help the complaint process go more smoothly.
The specific way to appeal an insurance denial differs depending upon the kind of insurance plan and the insurer.
Almost 20 million Californians are covered under health maintenance organization (HMO) plans, Randolph said. The California Department of Managed Health Care, which regulates the state's HMO plans and functions as policy group and consumer advocate, helps resolve complaints against these insurers.
The department's help center is staffed by attorneys and nurses who can answer questions about health plans or the complaint process, but the staff also assists simply by helping you get through to the right person at the insurance company. Sometimes the staff will set up a three-way call with you, an attorney (or nurse) and the insurer to work together to try to resolve the issue informally.
If the agency's staff cannot help resolve the issue, you can file a complaint with the department. A one-page form with your information goes to one of the department's attorneys, who has 30 days to resolve the dispute. In an emergency situation, the attorney deals with the issue within 72 hours.
If a complaint is still denied, you can request an independent medical review, in which a panel of doctors familiar with the condition looks at the case. The doctors review relevant medical data and render a decision that the health plan and consumer must follow. Randolph said consumers have a success rate of less than 50% when the complaint goes to a review board, but when they are successful, the process is worth the effort.
"With state departments, we have the force of the law behind us," she said. "If they [insurers] are not following the law, we have strong enforcement units."
The California Department of Insurance has regulatory authority over preferred-provider organizations (PPOs), which provide health insurance for approximately 6 million Californians. The department regulates licensing, marketing and policy administration. It, too, receives numerous complaints dealing with coverage, said Darrel Ng, senior press secretary for the department.
The consumer assistance process is similar to that of the Department of Managed Health Care. You can contact the department's call center for help understanding bills and for answers on what should be paid for under your policy.
"We as a regulator contact them [insurers] to make sure they have fulfilled their contract with the covered person," Ng said. "If it should be paid for, we will contact the insurance company and give them our point of view. Generally at that point, the problem will be solved."
If an insurer does not respond to a complaint within 30 days or continues to deny the claim related to issues including medical necessity, experimental treatments or denial of urgent medical services, you can file for an independent medical review through the department. A review board looks at the case, and a decision that is binding upon the insurance company is provided.
Medicaid (called Medi-Cal in California)
There are nearly 6.5 million California consumers covered under Medi-Cal. Information on how to file an appeal if a claim is denied is provided by the insurer when coverage begins and then annually thereafter.
If talking with the physician and the health plan doesn't resolve a dispute, you can file a complaint through the California Department of Health Care Services, which finances and administers the Medi-Cal program. The department can send a complaint form in the mail or you can fill it out online.
If a complaint is filed and the insurer refuses to pay for the service, you can request an independent medical review within six months of the time the claim was denied. The Department of Managed Health Care handles reviews.
More detailed information on how to file an appeal can be found at the Health Consumer Alliance's website at www.healthconsumer.org "> www.healthconsumer.org . The Los Angeles-based organization, whose goal is to help low-income people receive needed healthcare services, can also be contacted at (310) 204-4900.
Though few people actually file Medicare appeals, more than half of those who do get a decision in their favor, according to California Health Advocates, a nonprofit group that provides Medicare education and advocacy to California residents.
Each quarter, Medicare patients receive a notice that lists claims for the previous 90 days. If a consumer thinks that a claim has been wrongly denied, there are appeal details on the back of the notice.
Groups such as California Health Advocates and the state Department of Aging’s Health Insurance Counseling and Advocacy Program (HICAP) are equipped to assist Medicare recipients in filing an appeal. HICAP's local centers in California can be contacted at (800) 434-0222. The group offers information on rights and benefits and coverage denials, and can provide legal help at hearings. HICAP staff will come to the homes of individuals who cannot get to their office.
More information on how to appeal a denied Medicare claim can be found at the California Health Advocate website.
If you're not covered under a government plan or a managed-care HMO or PPO, Rothhaar said there is, unfortunately, little recourse if you are denied coverage.
But Randolph, from the California Department of Managed Health Care, said plans issued in California are regulated by the state and should provide some form of consumer protection, including complaint assistance and an independent medical review. If you have an individual plan and are not sure how it is regulated, her department can tell you where to go for help.
If you are covered by an employer who has an out-of-state policy, the plan will be regulated by that state. The state's department of insurance should be able to provide assistance on the grievance process.
Although there is an organization to help almost all consumers navigate issues with insurers, relatively few assist people with a billing problem from a physician or hospital.
"There is no regulation of physician pricing in this country unless they are being paid for by a public entity," said Rothhaar, of Health Access California.
Hospitals are required by state law to publish prices for their 25 most common inpatient and outpatient procedures. If you have received one of these and feel you have been overcharged, you can find the correct price online from the Office of Statewide Health Planning and Development.
For an issue with a hospital, Rothhaar recommends contacting her organization, writing a letter to the chief executive, copying a local legislator and, in general, trying to get some attention.
"Raise a stink, because it is fundamentally about the hospital's reputation," she said.
If the issue is with a doctor, there are even fewer options.
Candice Cohen, spokeswoman for the California Medical Board, recommends finding out the price before visiting the physician and taking the provider to small claims court if there is a problem. Her agency typically deals with complaints that are related only to some sort of fraud, rather than billing disputes, she said.