If your health insurance company refused to pay for the treatment or test your doctor ordered and your received, they likely didn’t look at your claim or patient records. 

This post is a part of our 30 Days of US Healthcare series. You can watch all the videos in this series on YouTube and learn more about the content behind the videos here. 

WHAT IS HAPPENING?

A medical director is a doctor who works for an insurance company reviewing insurance claims.

According to internal Cigna documents reviewed by ProPublica, one Cigna medical director denied a whopping 60,000 claims in just one month. 

WAIT. IT’S NOT POSSIBLE TO REVIEW 60,000 CLAIMS A MONTH. 🤨

Let’s do some quick math here.

If this medical director worked nonstop for 8 hours a day, 5 days a week, for an entire month, they would have to deny 375 claims every single hour. That’s a mind-blowing 6.25 claims per minute!

It’s pretty clear that reviewing each claim thoroughly, let alone reviewing patient records, is completely out of the question.

SO, HOW ARE CLAIMS BEING REVIEWED?

By an algorithm. Medical directors are then signing off in bulk on denials recommended to them by the algorithm. It’s really too bad that medical licenses are being used for evil, but here we are. 

To add insult to injury, insurance companies are adding lower-cost procedures and treatments to the denial list. They’re banking on us complaining bitterly to our loved ones about the denial but still paying the bill. 

THAT’S AWFUL. HOW CAN I FIGHT BACK?

The reality is that we can’t all fight back. Some of us lack the health or resources to devote to this task. But for those of us who can, there are 3 essential steps we can take.

1. Hold off on paying that bill.

While you may worry about your credit score if the bill goes to collections, paying right away leaves you with no leverage. Instead, communicate with your healthcare provider and let them know that you’re actively working to resolve the bill. Let them know that you are going to follow the steps below.

2. Request your claim files.

Insurance companies keep detailed records of every interaction, note, and decision related to our claims. These claim files include the details of what our insurers say about us and our cases.

We have the right to request copies of phone calls, emails, and other documents concerning our claims. Federal regulation requires access to our claim files for free. Access to this treasure trove of information can make a world of difference when building a strong appeal. 

The journalists at ProPublica put together an easy-to-use Claim File Request Template. They also provide step-by-step instructions on how to complete the form and submit a request.

3. Appeal your denial.

Armed with the knowledge from your claim files, it’s time to craft a compelling appeal. Appeals are challenging, but they are a crucial step in fighting for the coverage you deserve. To support your efforts:

• Get your hands on the massive plan document for your insurance policy. Brace yourself. This isn’t the 4-page summary. This document is about 100 pages long. In it, you will find the step-by-step process to appeal.

• Listen to the podcast, An Arm And A Leg, where they interview Laurie Todd the “Insurance Warrior” in a two-part series. She shares tips on how to think about and engage in the appeals process.

• Study the successful insurance appeal letter that Marshall Allen, author of Never Pay The First Bill, shares on his website.

IMAGINE IF WE JOINED FORCES TO DEMAND OUR CLAIM FILES, APPEAL, AND PUBLICALLY SHARE OUR STORIES.

Together, we can raise awareness of these malicious practices and make it less profitable for insurance giants to unjustly deny our claims.