MARIA CARR, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.
Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr's mind, arthroscopyseemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.
"When the denial came I was shocked," Ms. Carr said, "but I figured I'd just have to find a way to pay." The total bill for the hospital and surgeon fee was $21,225.
Ms. Carr's form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.
Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.
But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a localcharter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.
"I decided I would fight," she said. "After all, what did I have to lose?"
Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.
The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer's external review board, where an impartial medical expert weighed the evidence.
The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. "The expert felt UnitedHealth couldn't call the procedure experimental if it paid for other patients to have it," Ms. Carr said.
UnitedHealth ended up paying $12,282 for Ms. Carr's claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr's share was about $500.
"That's what the appeals process is there for," said Cheryl Randolph, a spokeswoman for the insurer. "We're glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to."
Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr's successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.
Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor's use of the wrong diagnostic or treatment code for your treatment.
Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr's case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.
Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar withinsurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.
But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.
"About 53 percent of appeals work in our state," said the Kansas insurance commissioner, Sandy Praeger. "That demonstrates that the process works."
Use the following advice to increase your chances of success in appealing a health insurance denial. As you'll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.