Name Insurance Coverage In:
Family Name Covered Under Plan:
Individual Covered & Subject to This Letter:
Social Security Number of Individual:
Their Case Number, if one is assigned:
Dear Sir or Madam:
On ______________ (Date), a claim was filed with you regarding _________________.
We received notice, see Exhibit 1 attached, that the claim was denied.
This claim should not have been denied for the following reasons:
Additional documentation is also attached; see Exhibit 2, supporting our claim.
Please review the new materials submitted in order to reconsider your denial of the claim.
Please call me after you have reviewed the information I have submitted.
Please call us in the next few days so we can both take care of this promptly.
With best regards,
Family Member Under Whose Name the Plan is listed
Enclosures: Exhibit 1 & 2.
Denial of Medical Insurance Claim, Response
This review list is provided to inform you about the document in question and assist you in its preparation. Denial of Medical Claims in the first round is like tennis, as they lob the ball over the net to “see what you will do.” It is standard practice for them. Your first job, then, is to answer immediately, if not sooner. Poundage in your response weighs heavily in their analysis of your both your claim and your conviction to pursue it.
Once you understand the game, you will be able to play it better. Think of it from their point of view: if just 10% of claims go uncontested, their bottom line improves immeasurably. As the numbers escalate, and I suspect it is a far higher number than 10% that don’t respond to the initial computer generated letter, this is an enormous profit center (they might say “screening” device) for them.
1. First, gather your documentation. Then put together a folder in which you keep your copies attached to this claim (start seriously or don’t start at all), including all exhibits.
2. Secondly, fax and mail them your response. Mark down in your to call list to phone them in 10 days if you have not heard from them.
3. Third, call them in 10 days if you have not heard from them.
4. Fourth, on this matter, start numbering your new exhibits 3 and up so you have a complete file to refer to when you request an appeal, if this claim is turned down. At each step of the denial process, their profit in turning you down declines (they know the concept of “sunk cost” though many organizations do not). Therefore, your odds of winning actually improve as you continue this process, despite the fact it is against normal human nature, which is to “stick to your position” and “dig in.” In this instance, it is all business. When it stops paying to argue, they do. One caveat: you can, of course, get a claim group that is outside of this norm. If so, still continue on. That will change as it has in our Health Organization. If you learn to develop a plan, as in tennis, and respond swiftly to each of their denials, you will become more efficient and they will red tag, or mark your file, you as an effective denial fighter—and pay you more often in the cycle.
5. You will note the bureaucratic flavor of our letter, especially the numerous headings at the top of the letter. In one sense, you are providing helpful information at the top of hour, so to speak. Immediately they can locate all pertinent information. Just as importantly, you have signaled them that you know how the game is played and will play it well. You have also held your emotional fire, personal attacks and the like, so they are more apt to want to pick up the phone and actually talk to you. Put yourself in their shoes: who wants to call a name caller if that can be avoided? Keep “otherness” or “the other person” in mind when responding to all legal inquiries; if you do so effectively you will be able to anticipate them and win more rounds in the legal game—and that’s what most lawyers consider it as a casual reading of the newspaper or media will demonstrate (and most of them don’t really like what they do; so this too, lets you put them in the good guy role of paying up).
6. This is a lifelong battleground. Be prepared. Treat it like a business too, sometimes, of course, in phone calls; both sides may resort to emotional appeals. Fine. It is still a business to them. Lob them right back. The people on the other end of the phone, by the way, didn’t establish the rules. Many of them would like to pay the claims more than they are allowed to do. If you sense this, try to get this claim denial person on your “file” so you can call them back in the future. It may be business to the company, but it will become personal to this person. This puts you in a vastly improved situation. Get after ‘em!
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