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8 tips for navigating a denied health insurance claim

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Cancer health insurance claims

Receiving a denial on your cancer health insurance claim can be a frustrating and perplexing experience, especially for breast cancer survivors. However, there are specific steps you can take to address this issue effectively. Here’s a guide on steps you can consider taking if your health insurance claim is denied:

1. Verify policy compliance:

Examine your insurance policy to ensure that you followed all required procedures, such as pre-certification or authorization. For specific items like prosthetic bras, implants, or wigs, ensure you have the necessary documentation, such as prescriptions and bills.

2. Contact the insurance company

Call your insurance company promptly to inquire about the reason behind the denial. If the explanation remains unclear, carefully review the Explanation of Benefits (EOB) form. Sometimes, denials can result from simple recording errors, such as missing services.

3. Keep records of all correspondence

Maintain copies of all correspondence with the insurance company, including letters and emails related to your claim. Make sure to note the claim number and policy or procedure code on all documents. Keep a record of the names of any customer service or claims representatives you speak with on the phone.

4. Consult your doctor

Seek assistance from your healthcare provider if questions arise regarding fees, charges, or procedures. Ask your doctor to write a letter to the insurance company, documenting and justifying the charges or procedures. Make sure to retain a copy of this letter.

5. Challenge experimental treatment denials

If your claim is denied due to the insurance company deeming a treatment experimental, work with your doctor to provide evidence from scientific literature supporting its use.

Your doctor can gather published studies and support letters from other oncologists who have used the same procedure. National organizations like the Patient Advocate Foundation can also offer support in this regard.

6. Request a formal review

Don’t give up if your claim is initially denied. Request a formal review in writing, as many claims denied initially are later approved during the review process. If the review still doesn’t yield a positive outcome, appeal the decision and advocate for another review.

7. Seek legal assistance if unable to resolve

In the rare event that none of the above steps result in a justifiable payment for your claim, consider consulting an attorney. National patient support organizations, such as the National Cancer Legal Services Network, can help you find lawyers in your state who specialize in cancer-related insurance issues.

8. Utilize patient advocate resources

Take advantage of patient advocate organizations like the Patient Advocate Foundation, which offer assistance in resolving problems and dealing with insurance issues related to insurers, employers, and creditors.

 

“Dealing with breast cancer is like a rollercoaster ride of emotions, but strangely, it’s the health insurance paperwork that often feels like the scariest loop. Navigating insurance has been one of the most stressful parts of my diagnosis” – Courtney, Stage 2 HER2+ breast cancer survivor and Outcomes4Me Community guide. 

 

Facing a denied cancer health insurance claim can be challenging, but by following these steps and seeking assistance from healthcare providers and patient advocate organizations, you can increase your chances of having your claim approved. Remember that you are not alone and there is support available to help you overcome this obstacle and focus on your health and well-being.

Discover a smarter way to stay organized!

Did you know you can use the journal feature in the Outcomes4Me app to keep notes regarding your claims, all in one convenient place with date and time stamps? Stay organized effortlessly and take control of your healthcare journey today. Try it now!

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