As AIโ Tools Emerge, Patients Increasingly Battle Healthโ Insurance Denials
Facing a denied health insurance claim can โขbe daunting, but patients have several avenues for appeal. A growing number are even turning to artificial intelligence for help โcrafting customizable appeal โฃletters, according to recent reports. Here are seven strategies to increase yoru โคchances of overturning a denial:
1. Understand Why Your Claim โฃWas Denied. Carefully review the Clarification of Benefits (EOB)โ you receive. It should detail the โคreason for the denial. Common reasons include the procedure being deemed โ”not medicallyโ necessary,” lacking prior โauthorization, or being considered experimental.2. Gather Supporting Documentation. โขCollect any facts thatโ strengthens your case,โ such as โฃletters from yourโค doctor explaining the medical necessity ofโ the treatment,โฃ relevant medical records, and any pre-authorization requests.
3. Write a Clear and Concise Appeal Letter. Clearly state the claim number, the โdate of the original denial, and the reason youโ believe the denial โwas incorrect. Focus onโ the medical necessity of the service andโค reference supporting โdocumentation.
4.Leverage AI Assistance. New AI-poweredโฃ tools are available to โhelp patients draft effective appeal letters tailored to their specific situation.
5. โInquire with Your HRโข Department. โIfโ your health insurance is through your employer, your planโฃ 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 claimโ is denied, particularly for issues like prior authorization.
6. Seek advocacy Support. Many โคstatesโข offer free consumer assistanceโฃ programs by phone or email โto help with filing appeals and understanding yourโฃ benefits.Organizations โlike the Patient Advocate โคFoundation also provide guidance and,in certain specific cases,one-on-one assistance,particularly for those with โsevere illnesses. The foundation’s website offers guidance about what toโค include in an appeal letter.
7. Raiseโข Awareness. โคPublic pressure can sometimes lead to overturned denials. Sharingโ your experienceโฃ onlineโ or contacting your state lawmakers can hold insurance companies accountable. State lawsโค regulate healthโฃ insurance, and legislators have the power to influence policy.
Resources:
CMS Consumer Assistanceโข Grants: https://www.cms.gov/cciio/resources/consumer-assistance-grants
Patient Advocate Foundationโ Appeal Guidance: https://www.patientadvocate.org/explore-our-resources/insurance-denials-appeals/things-to-include-in-your-appeal-letter/
KFF health Newsโฃ Priorโฃ Authorizations: https://kffhealthnews.org/news/tag/prior-authorizations/
Shareโค Your Story with KFF Health News: https://kaiserfamilyfoundation.wufoo.com/forms/w19lp8m31l8mow5/