As AI Tools Emerge, Patients Increasingly Battle Health Insurance Denials
Facing a denied health insurance claim can be daunting, but patients have several avenues for appeal. A growing number are even turning to artificial intelligence for help crafting customizable appeal letters, according to recent reports. Here are seven strategies to increase yoru chances of overturning a denial:
1. Understand Why Your Claim Was Denied. Carefully review the Clarification of Benefits (EOB) you receive. It should detail the reason for the denial. Common reasons include the procedure being deemed ”not medically necessary,” lacking prior authorization, or being considered experimental.2. Gather Supporting Documentation. Collect any facts that strengthens your case, such as letters from your doctor explaining the medical necessity of the treatment, relevant medical records, and any pre-authorization requests.
3. Write a Clear and Concise Appeal Letter. Clearly state the claim number, the date of the original denial, and the reason you believe the denial was incorrect. Focus on the medical necessity of the service and reference supporting documentation.
4.Leverage AI Assistance. New AI-powered tools are available to help patients draft effective appeal letters tailored to their specific situation.
5. Inquire with Your HR Department. If your health insurance is through your employer, your plan may be “self-funded” or “self-insured.” In these cases, your employer ultimately decides what is covered, not the insurance company. Appeal to your HR department if your claim is denied, particularly for issues like prior authorization.
6. Seek advocacy Support. Many states offer free consumer assistance programs by phone or email to help with filing appeals and understanding your benefits.Organizations like the Patient Advocate Foundation also provide guidance and,in certain specific cases,one-on-one assistance,particularly for those with severe illnesses. The foundation’s website offers guidance about what to include in an appeal letter.
7. Raise Awareness. Public pressure can sometimes lead to overturned denials. Sharing your experience online or contacting your state lawmakers can hold insurance companies accountable. State laws regulate health insurance, and legislators have the power to influence policy.
Resources:
CMS Consumer Assistance Grants: https://www.cms.gov/cciio/resources/consumer-assistance-grants
Patient Advocate Foundation Appeal Guidance: https://www.patientadvocate.org/explore-our-resources/insurance-denials-appeals/things-to-include-in-your-appeal-letter/
KFF health News Prior Authorizations: https://kffhealthnews.org/news/tag/prior-authorizations/
Share Your Story with KFF Health News: https://kaiserfamilyfoundation.wufoo.com/forms/w19lp8m31l8mow5/
