10/ 30/ 2007
As if navigating the rough waters of health-insurance coverage weren't daunting enough, employers and employees can be completely overwhelmed when a health-insurance claim is denied. Here are a few tips to consider if you face a denial of coverage.
Don't panic: The reason for the denial could be as simple as an error or the insurance company not having sufficient information to approve your claim. Cross-reference the denial letter with your health-insurance policy handbook. If it looks like a mistake, call your insurance company and also talk to your workplace's plan administrator. To identify any potential errors, match your EOB (explanation of benefits) with any statements from your doctor's office.
Talk to your doctor: Your doctor has a vested interest in your claim being approved--that's how doctors get paid after all. Ask your doctor to write a letter to the insurance company explaining the reason for the treatment. The explanation could be sufficient for the insurance company to reconsider or reverse its decision.
Appeal: Most insurance companies allow policyholders to appeal a claim denial. Find out the terms of the appeals process, including deadlines. Make sure to submit comments in writing and keep detailed records of communications with the insurer.
Contact the authorities: The insurance department in your state can help you if your claim is denied. In addition to finding helpful tips and resources for consumers and small businesses, you can also file a complaint. Find your state through the National Association of Insurance Commissioners.
True or False?
The rules and regulations governing an individual who buys a policy are the same as an employer-sponsored plan in the small-group market.
If you answered false, then you are correct! Employers are the primary source of health insurance in the United States today, with more than 160 million people covered by employer-sponsored plans. However, another 17 million Americans--including those who are self-employed, work for companies that don't offer insurance or are retired but not yet Medicare-eligible--buy their own coverage outside of the group market. These markets are regulated state by state, and in most states, the small-group market and the individual market operate under different sets of rules and regulations. The chart at right outlines the basic differences between small-group and individual insurance. Understanding these basics is critical to becoming a more educated consumer, but this chart is by no means exhaustive. To learn more about specific requirements that affect you, be sure to consult an insurance professional in your state.
