Writing Winning Insurance Appeal Letters
Susan Mina Agrawal
This is a slightly revised version of an article that appeared recently in the e-magazine Complex Child. It is printed here with permission. Complex Child can be found at www.ComplexChild.com. Note that while this article was initially written for parents, the strategies outlined can be applied in a wide range of circumstances.
Like many parents of children with complex medical issues, we receive many insurance denials. We probably average three a week. Many of these are simple to resolve, but I have come up with a variety of strategies to respond to even the most difficult insurance denials.
What I typically do is write a letter from me (the parent) describing in detail why the appeal should be granted. Surprisingly, much of the time just this one letter will win the appeal. If it does not or the insurance company requests a physician’s letter, I ask the physician to mail or fax me the letter and add my own letter to it, supplementing the physician’s statement.
Here are some of the strategies I use when appealing a denial, followed by a sample letter with instructions below. Good luck!
Show Them the Money
Insurance companies care about profit. The best way to win an insurance appeal is to prove to the insurance company that paying the claim in question will save them money. Every appeal letter I write, unless it’s in response to an error in coding or processing, includes a statement on how the item or procedure in the claim they are denying will save them money in the long run. I most commonly cite how approving this claim will prevent future hospitalizations.
Our insurance company, for example, refused to pay for GJ-button extension sets because my daughter is not tube fed. She uses the extension sets for gastric drainage and for medications through the J-tube, and receives all of her nutrition parenterally. 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 her fourteen J-tube medications to all be given IV, at a cost of approximately $1000 per day. The appeal was approved immediately.
Check for Errors
Many times claims are denied because of simple 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 appeals 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, no matter how often you report that you have it. Sometimes all you need to do is call them monthly to remind them that your child’s secondary insurance is Medicaid and they need to process your claims.
Don’t Give Up
I have fought some appeals for as long as twelve months. The insurance companies seem to 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. The insurance company often sends 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! My daughter, who does not walk, sit, or even hold her head up, had her tilt-in-space wheelchair soft-denied three times. The first time the insurance company wanted a physician’s functional assessment (the initial assessment had been done by an equipment specialist); the second time they wanted a statement as to whether she could self-propel a chair or not (a question that should have had an obvious answer based on her two functional assessments); and the third time they wanted a photograph of the chair. We won after submitting all of the requested information.
Co-author Your Letters of Medical Necessity
Let’s face it. Oftentimes your child’s doctor does not know the 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 e-mail 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 possibly a more accurate letter. I also 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.
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.
Cross Your t’s, 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 your letter, make sure all pages contain your child’s name, the insurance identification number, and the claim number. If you fax your letter, make sure you include a cover page listing how many pages are to follow and what they are.
Forget the Sob Story
Insurance companies couldn’t 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. Including these sorts of statements in your letter may get the letter thrown into the garbage pile. Insurance companies want facts.
Use a Case Manager
Some insurance companies have case managers who handle children with multiple medical issues. See if you can get one. Sometimes they can be extremely helpful in getting appeals processed, though other times they can be utterly useless. 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. Sending the case manager a photo of your child often helps to get the case manager to work harder on behalf of your child. 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 that you will never win.
Check the Laws in Your State
Sometimes states pass laws that require insurance companies to cover certain things, like medical formulas for certain diagnoses or ongoing therapies for children who are not expected to “rehabilitate.” Check your state’s regulations to see if this applies to you.
Appeal to Your Human Resources Department
Your employer’s human resources department is responsible for negotiating the contract with the insurance company. 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.
Know When to Appeal to Outside Regulators
In general, threatening is not a good idea. But if the insurance denials are causing your child to be denied appropriate medical care, by all means threaten to sue or appeal to whatever state or local boards regulate insurance in your area.
Finally, a sample letter for appealing a denial is below, or click here for a copy of the letter in PDF format.
Sample Insurance Letter
Your phone number
Your child’s name
Your insurance ID number
Your group number
Your claim number for this specific claim
Nasty Insurance Company
10 Denial Drive
Profit, IL 60000
To Whom It May Concern:
Start with a brief introduction, including your child’s name, age, and primary diagnosis. Follow this with a brief description of the claim. Finally, briefly state why the insurance company is wrong in denying the claim:
I am writing this letter on behalf of my daughter, Always Denied, who is two years old and is diagnosed with cerebral palsy. This letter is in regards to claim 10000, denying XYZ Valves as not medically necessary. These devices are essential in preserving her health and significantly reduce her need to be hospitalized. Moreover, they significantly lower her health care costs by providing a way to feed her through her gut.
Give a brief description of your child’s medical conditions and relevant equipment. List as many diagnoses as you can and use as many medical terms as possible (such as gastrostomy instead of G-tube):
Always Denied has a wide variety of medical problems, including cerebral palsy, seizures, hydrocephaly, gastroparesis, reflux, hearing impairment, and sensory processing disorder. She has a gastrostomy for feeding, a VP shunt, and requires an elemental formula. She vomits multiple times per day.
Explain why you need the item or procedure, making sure to show it clearly benefits the child:
Because Always Denied’s stomach does not empty well due to gastroparesis, she vomits her formula as many as ten times per day, and is very bloated and in pain. The XYZ Valves allow her formula to slowly drip into her stomach as it empties, while simultaneously venting out the air. They reduce her pain and vomiting dramatically, often stopping it completely.
State what would happen if this item or procedure was not approved. Then show how that will lead to additional costs, such as more hospitalizations. Feel free to state that this will reduce costs, but do so tastefully:
Without the XYZ Valves, Always Denied will continue to vomit and will be at high risk to aspirate or develop aspiration pneumonia and other respiratory complications. She has been hospitalized three times for aspiration and other respiratory complications in the past two years. She also will likely struggle with esophageal damage, tears, and other damage due to daily vomiting; a recent endoscopy already showed damage to her esophagus. Reducing her vomiting will directly reduce the number of hospitalizations for aspiration pneumonia and other complications of frequent emesis such as dehydration, dramatically reducing her medical costs.
Reference your attached medical records in an easily understandable format:
Attached please find several medical documents, as well as information on the XYZ Valve. These include:
Documentation of vomiting from a recent hospitalization
Report from endoscopy showing esophageal damage from vomiting
Report from chest CT showing aspiration damage to the lungs
Discharge report from a recent hospitalization for aspiration pneumonia
XYZ Valve brochure
Sum up your arguments, just in case they missed it the first time:
In order to preserve the health of Always Denied and prevent costly future hospitalizations, she needs to receive thirty XYZ Valves per month.
Thank them, even if you don’t want to:
Thank you for attending to this matter.