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How Family Caregivers Can Deal With Insurers When Making a Claim or Appeal

Protect your rights and maximize your chance of getting your claim paid

Making sure every detail is covered
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As my mother was being loaded into an ambulance transport to take her from one hospital to another for emergency brain surgery, she asked me to find out who the neurosurgeon would be and if he was in her insurance network. Completely panicked about the possibility that she had brain cancer, I said, “Are you kidding me? I really don’t think that matters right now!”  She said, “Oh, yes, it sure does!” 

This was a few years ago, before the recent federal law that protects patients from being overcharged by out-of-network doctors in emergency cases. Nowadays patients don’t have to worry about choosing lifesaving surgery or pushing it off to another day to find an in-network doctor. As a young caregiver taking care of my single mom from that day forward, I felt my heart skip a beat whenever bills came in. She had extensive, complex treatment. We both knew that collectively, we would not be able to afford a significant out-of-pocket outlay, but that her cancer was so advanced, she could not afford not to get the best treatment we could secure. In my mind, it was the difference between life and death for Mom, and between financial stability and bankruptcy for us both down the road.

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At the time I was caring for her, I was an insurance defense attorney. My job was to defend insurance companies that had denied their customers’ insurance coverage (denying means refusing to pay for a claim). With that line of work and my new life of caregiving, I learned a lot about how the insurance carriers review their claims and make decisions to decline to pay, and what customers can do to maximize their chances of having their claim covered or a denial overturned.

Get paperwork in order

First thing, make sure that your caregiver (the person who is helping you currently or that you expect will assist you with any future care or treatment) has all the necessary legal documents. A power of attorney and health-care proxy/surrogate designation will give caregivers the legal authority to go to bat with an insurance company if you are unable to do so yourself. Without these documents, the insurance company is not likely to provide much, if any, information to a person who’s not their customer.

Member services at your insurance company and your medical providers can help you or a loved one understand the basics of a policy. In the insurance documents there will be a page titled “summary” or “declarations”; this will provide an overview of your plan. This page, an insurance card or the plan website should provide information on whether you or a family member can use doctors who are “out of network” of your policy, your deductible (the amount of money you’re responsible to pay before insurance kicks in) and whether you have coinsurance responsibilities for medical bills. Work with member services and your doctor’s office to help you understand whether preauthorization from the insurance company or a referral for any of your recommended treatments or medicines is required.  

Review all policy documents

If the insurer has not provided a full copy (not just a summary) of your policy, ask for one. The insurer will be relying on the policy — especially the section titled “exclusions” — to determine the amount they cover. Anything that is listed under exclusions won’t be covered and the claim will probably be denied. Small details matter. If there are any required processes that are not followed, it will result in a denial. Be sure to confirm with medical providers how they are going to bill the treatment — find out the name of the procedure or treatment and what medical codes correspond to that treatment so you can verify with your insurer that the correct ones were submitted. The code numbers the medical provider inputs into your file can make the difference between denial of coverage and covered care.

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When a claim is denied

If a claim for service is denied, you will most likely find it in your “Estimate of Benefits,” a statement provided by an insurer that describes what costs it will cover. Step into action as soon as you learn that your insurance company is attempting to deny your claim. As a policy holder (or appointed designate), you have a legal right to appeal if you disagree with the insurance company’s decision. Your policy will outline the appeal process, and there will be specific time frames that must be followed. Take the time to review the requirements for appeal listed in the policy documents or on the plan website, or if you are a Medicare Recipient, in the Medicare & You handbook.

Be steadfast: The appeals process can take some time. You may be able to appeal internally at the insurance company or enlist an outside grievance committee. Your doctor will need to advocate on your behalf. They can have a peer-to-peer conversation with the medical reviewer for your case or write an appeal letter explaining what they are treating you for, your medical history, why the treatment is recommended and any information or evidence that would support coverage. If your situation is urgent, your doctor should express that clearly.

As you’re going through the appeals process, request copies of all the insurance company’s paperwork, such as their claim diary and the forms that were submitted to the company. It could be something as simple as a typo or misclassification that resulted in your claim being denied.

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Document everything

This is the time to be hyperorganized, which means documenting everything in a chronological way. Write down the date and time of any phone calls you have with your doctors and insurance company. Obtain the name of the person you’re speaking with, their ID number and reference number for the call. Ask if the conversation is being recorded, and ask if you may record it (do not record it without the knowledge of the person on the other end of the phone). Request an email confirmation of what was discussed, or follow up by email with your understanding of the conversation. Scan or photocopy all your correspondence so you have a record of what was sent and said, and when.  

Consult professionals

Your state may have a consumer assistance program or healthcare ombudsman to help bring your claim to a resolution. A qualified lawyer will know what the state law requirements are to bring a case to court against an insurer and make sure that you meet all the conditions needed before you file a lawsuit.

Even though it may feel like an impossible system sometimes, you do have rights and your insurer has responsibilities to you as its insured. If you get a surprise bill from your insurance company, visit or call the No Surprises Act Help Desk at 800-985-3059.  If you get an unexpected denial of coverage, don’t take no for an answer. Follow the steps above and be persistent, and you may find that the claim is resolved in your favor.