In 2008, we published an article on writing winning insurance appeal letters in Complex Child Magazine. It has always been one of our most popular articles, and has been shared and excerpted thousands of times. Since 2008, however, the insurance appeals process has changed slightly, providing more routes of appeal for most families. In addition, insurance plans that are part of the marketplaces set up by the Affordable Care Act have greater protections that allow for different types of appeals.
In order to include this new information, we are updating the original article below to include the recent changes in appeals.
Step 1: Take a Deep Breath and Prepare for the Fight
Like most parents of children with disabilities, you are likely to receive numerous denials from your insurance company. Insurance companies rely on the fact that most people are too busy to appeal, or that they do not understand that they have the right to appeal. Many times they deny an item the first time simply because they hope you won’t bother to appeal their decision.
If you receive one of these denials, don’t panic! Recognize that denials are a business strategy for insurance companies to save money. It is nothing personal against you or your child. It is all about their profits. If they can get away with not paying for an item or procedure, they will most certainly issue a denial, even if they have no rational explanation for the denial.
Over the years, I received denials for a surprisingly large number of items and services. We were denied a wheelchair for a child who doesn’t walk (multiple times!), private duty nursing, enteral supplies because my child was also on intravenous nutrition, multiple medications, speech and feeding therapy, communication devices, and numerous pieces of equipment from standers to lifts. I fought and won almost all of them using the techniques in the following sections.
Take a deep breath and go for it!
Step 2: Check for Processing Errors
Before writing a huge long medical appeal, make sure to check the claim for errors. Many times claims are denied because of simple errors and mistakes, such as improper coding or wrong identification numbers. Some of these can be handled with the insurance company, while others must be taken up with the provider. These are usually pretty easy to win, but often require a request to speak to a supervisor.
If your child has secondary Medicaid, many claims will be denied because the doctor or hospital submitting the claim has indicated that you have secondary insurance. The insurance company denies the claims because you have not reported to them that you have secondary insurance. In reality, since most private insurance companies do not work with Medicaid, they keep no record of Medicaid in your file, even if you report that your child has Medicaid to them every month. Sometimes all you need to do is call them to remind them that your child’s secondary insurance is Medicaid and they need to process your claims.
Step 3: Contact Your Case Manager
Some insurance companies have case managers who handle children with multiple medical issues. See if you can get one, because sometimes they can streamline the appeal process. We had one case manager who was always able to appeal our private duty nursing coverage, and she successfully won approval in just hours. Other times, case managers can be utterly useless. Another one of ours always asked for my child (who was nonverbal) when she called, gave us a list of lawyer websites as “information” about cerebral palsy, and never once facilitated an appeal.
If you are one of the lucky ones with a case manager who is actually willing and able to help you, use him or her to your advantage. Sending the case manager a photo of your child often helps personalize your child for him or her, which may help the appeal.
But don’t forget that the case manager ultimately works for the insurance company and his or her goal is still to save them money. You can appeal even if the case manager says it is not worthwhile or you will never win.
Step 4: Check Your State Laws and Essential Health Benefits
In some cases, states may have laws that force insurance companies to pay for certain items or services. In addition, the Affordable Care Act mandates that certain essential health benefits be covered by all plans. Knowing what your rights are can make an appeal go through much more rapidly.
State laws commonly mandate coverage for enteral or metabolic formulas, autism services or therapies, hearing aids, and other items and services. Always check with your state and advocacy organizations related to your child’s condition to find out if there are any state coverage requirements. Note that state laws may not apply to large self-funded insurance plans, which are usually provided by large companies and corporations.
Essential health benefits are required for individual plans purchased on the marketplaces created by the Affordable Care Act. Essential health benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric oral and vision care. The category “rehabilitative and habilitative services and devices” includes all durable medical supplies and therapies. If the service/item you need is part of this list, it must be covered under your marketplace plan.
Step 5: Write or Co-Author Your Own Appeal
Many times, all it took to win an appeal was submitting a simple letter of explanation to the insurance company. I did not need to bother my daughter’s physician for a letter of medical necessity at all. I simply wrote my own letter and attached some medical documentation.
Even if the insurance company requests a physician letter, consider ghostwriting it for the physician. Let’s face it. Your child’s doctor probably does not know your child’s day-to-day needs like you do. Nor does he or she have a lot of time to dedicate to writing letters to insurance companies. If you want a good letter, write it yourself and then email it to the doctor. He or she can edit it as needed, cut and paste it onto letterhead, and be done with it in minutes instead of days. This means a quicker turn-around time for letters and a more accurate letter.
Sometimes physicians or offices are not comfortable with you ghostwriting a letter. If that is the case, follow their procedures, but consider submitting a supplemental letter with additional information if the physician’s letter is too simple. I always have the doctor mail or fax me the letter so I can submit it myself with whatever further documentation I have to support the appeal.
Step 6: Use Proven Strategies When Writing Your Letter
Show them the Money:
Insurance companies care about one thing and one thing only: profit. The best way to win an insurance appeal is to prove to the insurance company that paying the claim in question will actually save them money. Every letter I write, unless there has been an error in coding or processing, includes a statement on how I am saving them money in the long run. The most common one I use is that approving this claim will prevent future hospitalizations, injuries, or expensive other negative medical consequences.
For example, our insurance company refused to pay for GJ-button extension sets because my daughter is not tube-fed. She used the extension sets for gastric drainage and for medications through a J-tube while receiving her nutrition intravenously. I argued to the insurance company that they could pay for the extension sets at a cost of about $200 per month, or they could pay for 14 J-tube medications to all be given IV, at a cost of approximately $1000 per day. The appeal was approved immediately.
Attach Medical Records:
Include any and all medical records that would support your appeal, referencing them in your letter. Any medical documentation that supports the claims you have made in your letter will really help your appeal get through medical review unscathed. Also attach a copy of the insurance denial for them to reference. If you are appealing a denial for a product, include a brochure about the product.
Consider Attaching Medical Studies or Citations:
If you are appealing a medication or device that is experimental or only used in certain conditions, you may want to include medical studies or citations with your letter. For example, my daughter was initially denied The Vest, a respiratory device that shakes out secretions. Along with help from the manufacturer, we submitted about 10 citations of medical studies showing how the device reduced pneumonias and other respiratory complications, therefore preventing hospitalizations and other expensive care.
You can simply summarize the medical studies in your letter and cite the source as a footnote. Sometimes attaching an abstract for a study is also worthwhile. In general, it is not necessary to submit full articles or studies.
You can find abstracts and articles for free by using PubMed and searching for the device or treatment you need.
Cross Your T’s and Dot Your I’s:
Don’t neglect spelling and grammar. Use as many medical terms as you can (appropriately of course) and try to write in as scholarly a style as you can. Whether you fax or mail in your letter, make sure all pages contain your child’s name, the insurance identification number, and the claim number. If you fax your letter in, make sure that you include a cover page listing exactly how many pages are to follow and what they are.
Forget the Sob Story:
Insurance companies could care less if your family is struggling financially, if you have spent many hours fighting this appeal already, or if this procedure will give you another month with your dying child (dead children don’t cost them money, after all). Including these sorts of statements in your letter usually gets them thrown into the garbage pile. Insurance companies want facts, information on how this will save them money, and nothing else.
Step 7: Submit Your Appeal and Await Your Decision
Once you have written your appeal and gathered all of your supporting evidence, submit the appeal following your insurer’s directions. Insurance companies are required to include a statement on denial letters that lets you know how to appeal. If you are unsure, call your plan’s customer service hotline.
Step 8: Don’t Give Up…Jump through Their Hoops
If your appeal is still denied, don’t give up! I have fought some appeals for as long as twelve months. The insurance companies use the “hassle factor” to try to get you to give up. They will deny and deny again for pointless reasons, all the while hoping that you will give up the fight.
Don’t give up! Medical equipment, like wheelchairs and beds, often is not approved until you jump through many, many hoops. They often send out soft denials, or requests for further information, in order to slow down the approval process and get you to give up. Jump through the hoops and you will almost always win.
Step 9: There are Options, Even If You Lose Your Appeal
Even if you lose your appeal, there are other options that you can still use to try to get an item or service covered. These include requesting a peer-to-peer review, external review, appealing directly to your employer, and appealing to outside regulators.
In some cases, your insurance company may offer peer-to-peer review. This consists of a medical professional, usually a physician or pharmacist, from the insurance company discussing the medical necessity of an item or device with your child’s physician. It is a simple way to communicate complex needs, and often will work in your favor. Your physician typically needs to initiate the process.
The Affordable Care Act strengthened the appeal process considerably, and now allows anyone who has received a denial to ask for an external review of the denial by an independent party. While each state has its own external review process (and some states or plans use a federal process), they all must follow the same general rules. To request an external review, you must file a request in writing with your insurance company within 60 days of your final denial notice. The independent reviewer then has 60 days to make a decision to side with either you or the insurance company, and the decision is legally binding. In my experience, insurers will request a pediatric specialist who does not know your child to examine the claim. All of our external reviews were won, so this can be a very powerful tool for families.
If your insurance plan is through a large company or union, it is most likely self-funded and negotiated. This means that the union board or human resources department is responsible for negotiating the contract with the insurance company, and determining in part what should be covered. Since they can just as easily take the contract to another insurer the next year, these people actually have some power over the insurers. If the insurance company continues to deny your claim, bring it to the attention of human resources and have them help make calls on your behalf.
If denials are causing your child to be denied appropriate medical care and you’ve exhausted all appeals, you still have two options: appeal to the state or local insurance boards regulating insurance in your area, or file a lawsuit. Hopefully you will never get to this point! If you have followed all the preceding steps, you most likely have already won your appeal.