most common questions about appealing a health insurance denial

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Health Insurance Appeals
Questions and Answers

Phone:
805-587-2197

order an appeal letter

Health Insurance Appeal Questions and Answers

• Do I have to appeal?  What if I just don't pay the bill?

  If you are billed by your medical provider and you decide not to pay, the medical provider may send you to collections, which may negatively impact your credit rating.  Many times we have heard that a patient, in trying to purchase a new home or car, find out at that moment that their bill is in collections and are unable to complete the purchase. 

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• Is appealing a claim difficult?

  Appealing a claim denial may sound complex, but Health Symphony takes the complexity out of this process by having readily available appeal letters that have been used by actual medical providers.  All that would be required is to fill in the blanks of the appropriate appeal letter and send it to the health plan.  The cost of the appeal letters is relatively inexpensive and really only requires a little bit of time and effort.   Order Appeal Letters

• What is the likelihood that my denial will be overturned?

  We have found that 60% of all claim denials could be overturned when appealed with a properly worded appeal letter.  Many times health plans make mistakes or they just require some additional information or insight into the claim for them to make their decision.  

• Can' t someone appeal for me?

  There are health care attorneys that may assist.  But they may take only large dollar cases and are themselves very expensive.  You don't need to be a health care and insurance professional to appeal a claim denial, you just need the right tools. 

• What if my appeal is denied?

  Try again.  Health plans must continue to review appeals as long as there is new information presented each time.  Additionally, it would be helpful to call and follow up on the appeal and try to get a health insurance representative on your side.  It just requires one person at the health plan to change their mind and pay the claim.  If the health plan continues to deny the claim, you could file a complaint with the State Department of Insurance. 

• How do I know if my appeal worked?

  Health Plans will review the appeal letter and determine if your argument is justified with the information submitted.  If the health plan agrees to overturn a denial, they will reprocess the claim and resend an explanation of payments (EOB) and include a payment.

• What percentage of appeals are overturned.

  Nearly 40% of appeals are paid in the first appeal attempt.  This may seem high, but knowing that health plans make mistakes and they may have interpreted the policy incorrectly or agree to waive a policy or restriction will result in more claims getting paid.  If your appeal is denied, continue trying.  As long as the health plan receives new information, they must continue to review your appeal.

• If my claim continues to be denied, do I pay the doctor what they ask?

  You should attempt to negotiate with your physician for a reduced amount.  Generally a 50% discount would be considered to be a good amount.  The reason for the reduced payment is because health plans also don't pay the full amount and consumers without insurance should be given the same benefit.  But, make sure your physician has accepted this and that you don't assume that you would only need to pay 50%.  Not having an agreement with an open balance could result your balance being sent to Collections and impact your credit rating.