When a health insurer rejects your claim, here’s how to fight back


A former Aetna












AET, +0.56%










  employee said that doctors don’t review patient records at the major insurer when making decisions regarding claims — and that may not be an uncommon practice.

Jay Ken Iinuma, a doctor who served as Aetna’s medical director for Southern California between 2012 and 2015, said in a deposition under oath that he never reviewed patients’ files when making the choice to approve care or not. That task, as CNN first reported, fell to nurses.

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“Patients should always be able to trust that a health plan’s internal decision to deny or limit coverage is guided by a highly-qualified company physician who has reviewed all relevant information in the medical record,” said American Medical Association president David Barbe.

Though nurses receive medical training, they may not have the knowledge to determine the effectiveness of a given therapy in treating a medical condition. And that could mean that a patient may have their claim rejected, even though it should have been approved.

How the Trump administration could make claims more complicated

Though uncommon, when claims are denied, consumers should ask who was responsible for making that decision, which is often an opaque process, said Eliot Fishman, senior director of health policy at Families USA, a nonprofit consumer health advocacy organization.

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Fighting back could get all the more difficult if the GOP’s health care plans come to fruition. In October, President Trump signed an executive order directing federal agencies to explore the sale of health insurance policies across state borders, among other things.

The GOP argues that such offerings could help to drive down health care costs for consumers. But Fishman warned that it could also cut off at the knees consumers’ ability to appeal a denied claim, since these products wouldn’t come with same degree of oversight necessarily.

How many claims are denied by insurers?

Most medical claims are approved — though the exact figure varies from insurer to insurer.

  • Medicare denied 4.9% of claims, more than any other insurer, according to a 2013 report from the American Medical Association.
  • Anthem












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     withheld approval from 2.6% of claims. Aetna, Humana












    HUM, +0.65%










    Cigna












    CI, -0.11%










      had a denial rate of less than 2%.

But this could change if the current administration rolls back Obamacare. Those figures are significantly lower than the era before the Affordable Care Act. In 2008, Aetna denied 6.8% of its claims, according to the AMA.

What should I do if a claim is denied?

  • Document everything. This includes medical test results and doctors’ notes to childhood issues. Consider evidence from clinical research and peer-reviewed journals to demonstrate the therapy’s effectiveness.
  • Stick to the facts and avoid emotion. They might describe why their rheumatoid arthritis makes work difficult, but shouldn’t say how sad it makes their kids feel that they have trouble playing football with them.
  • Find a connection on the inside. Identify a doctor within the insurance company and connect him or her with your physician. “It can make a big difference,” Fishman said.
  • Don’t act alone. You’re dealing with a bureaucracy, so double check every detail. In particular, make sure the physician used the right billing code. One small error could cause weeks of delay.
  • Soul-searching over insurance claims in California
  • California Insurance Commissioner Dave Jones, meanwhile, has launched an investigation to determine if this alleged practice at Aetna was widespread. Some say that it could be a nationwide problem within the insurance industry. “These issues come up all the time,” Fishman said.
  • In a statement, Aetna said that its medical directors do “review all necessary available medical information” when evaluating cases, adding that such reviews are “an integral part of their yearly review process.”



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