Tips for fighting an insurance claim
You can ask your health insurer to reconsider if it rejects a claim or refuses to pay for treatment you believe is medically necessary. This is how the state's two biggest insurers handle appeals:
Blue Cross of Idaho
In 2006, Blue Cross of Idaho processed 743 appeals from patients or their families, down from 838 a year earlier. Blue Cross ruled in members' favor in 359 of the cases, or slightly more than half, said Karen Early, director of corporate communications at Blue Cross.
Here are the rules Blue Cross of Idaho says it follows:
Write the company to notify it of the problem. Include all the medical documents from your doctor or hospital that will help the company's medical-review team decide your case. Don't just send a letter from your health-care provider. The company needs to see copies of medical records, Early said.
By law, both Blue Cross and Regence BlueShield of Idaho must decide your case within 15 days if you're asking them to cover a treatment you haven't received yet or 30 days if you're asking your insurer to pay on a bill you already have.
The only exception is if the companies need more time to get your medical records. The average turnaround time at Blue Cross is much shorter, just 11 days, Early said. If you don't like Blue Cross' answer, you can try twice more, getting more documentation for your case.
Except in extremely rare cases, the company will not approve payment for treatments it considers investigational or experimental. The third appeal is for cases involving those issues, which go to an independent physician review organization with no ties to the insurer.
Regence BlueShield of Idaho
A total of 927 customers filed appeals in 2006. Customers got their way in 42 percent of those cases. This is what you do, according to spokeswoman Georganne Benjamin:
File your claim within 180 days after Regence first says no. If you still get a no and want to pursue a yes, do it within 180 days. This time, a special internal appeal panel will check out your case.
That's the end of Regence appeals unless you are arguing medical necessity or the treatment you want is experimental. Those cases go to an independent physician review board that is not controlled by Regence.
If you're still getting no for an answer and you remain convinced it should be yes, you can take your case to the state Department of Insurance. Call 334-4250. "We encourage consumers to call us," said Gina McBride, supervisor of consumer affairs for the department. "Call and ask questions, and then they can decide whether they want to work the complaint process with us."
The department gets about 800 consumer calls about health, life and other insurance each month, down a bit from recent years. About 10 percent of callers go on to file complaints, McBride said.
Some cases are easy, like helping a patient get necessary records from a health-care provider. Others are tougher. Determining medical necessity usually is beyond the scope of the department, unless a company has obviously breached the terms of its customers' policies. And it rarely can do much about rate increases.
Lately, more people are complaining about prescription drugs. Their insurers may not pay for a drug their doctor recommends. The department is deciding how to proceed in those cases. "We are still looking at that and shaking our heads," McBride said. The department does not provide legal advice, but some people who file complaints go on to hire attorneys.
You can file a complaint with the department one of two ways:
Send a letter to Idaho Department of Insurance, Attention: Consumer Assistance, P. O. Box 83720, Boise, ID 83720-0043
File online at www.doi.state.id.us/Consumer/complain.aspx
Provide as much information as you can about the situation, including policy numbers, company name and details of the situation. The more information the department has, the faster it can help you.