Fighting a Health Insurance Denial? Here Are 7 Tips To Help

When Sally Nix discovered that her health insurance company would not pay expensive treatment and recommended by the doctor to relieve her neurological pain, she prepared for the battle.

It took years, a chain of contradictory decisions and an insurer switch for health before it was ultimately approved. It started treatment in January and now channels time and energy to help other patients fight against denial.

“One of the things I say to people when they come to see me:” Don’t panic. This is not a last no “”, said Nix, 55, from Statesville, in North Carolina.

To control costs, almost all health insurers use a system called prior authorization, which obliges patients or their providers to request approval before being able to obtain certain procedures, tests and orders.

The refusals can be on appeal, but almost half of the insured adults who have received a prior authorization refusal in the past two years reported that the call process was somewhat or very difficult, according to a July survey published by KFF, a health -purpose organization of health information which includes Kff Health News.

“It is overwhelming by design”, because insurers know that confusion and fatigue make people abandon, said Nix. “That’s exactly what they want you to do.”

The good news is that you don’t need to be an insurance expert to get results, she said. “You just need to know how to push back.”

Here are any advice to consider in the face of a prior authorization refusal:

1. Know your insurance plan.

Do you have insurance thanks to your work? A plan purchased via healthcare.gov? Medicare? Medicare advantage? Medicaid?

These distinctions can be confusing, but they have a lot. Different categories of health insurance are governed by different agencies and are therefore subject to different previous authorization rules.

For example, the plans of the federal market, as well as the Medicare and Medicare plans, are regulated by the United States Ministry of Health and Social Services. The plans sponsored by employers are regulated by the Ministry of Labor. Medicaid plans, administered by state agencies, are subject to state and federal rules.

Learn the language specific to your policy. Health insurance companies do not apply the prior authorization requirements uniformly in all plans. Read your police closely to ensure that your insurer respects its own rules, as well as the regulations established by the State and the Federal Government.

2. Work with your supplier to call.

Kathleen Lavanchy, who retired in 2024 from a job in a rehabilitation hospital for patients hospitalized in the Philadelphia region, spent a large part of her career communicating with health insurance companies on behalf of patients.

Before contacting your health insurer, call your supplier, said Lavanchy, and ask to speak to a medical care manager or someone from the office who manages prior to authorization.

The good news is that your doctor’s office can already work on a call.

Members of medical staff can act as “your voice,” said Nix. “They know the whole language.”

You or your supplier can request a “peer-to-peer” examination during the call process, which allows your doctor to discuss your case by phone with a health professional working for the insurance company.

3. Be organized.

Many hospitals and doctors use a system called mychart to organize medical records, test results and communications so that they are easily accessible. Likewise, patients must keep track of all documents related to an insurance call – telephone calls, emails, postal mail and integrated messages.

Everything must be organized, either digitally or on paper, so that it can be easily referenced, said Nix. At one point, she said, her own files have proven that his insurance company had given contradictory information. The files were “the thing that saved me,” she said.

“Keep an incredible paper path,” she said. “Each call, each letter, each name.”

Linda Jorgensen, executive director of the project of resource on special needs, a non -profit organization offering online resources for disabled patients and their families, advised patients who fight against a denial to specifically keep paper copies of everything.

“If it’s not on paper, it didn’t happen,” she said.

Jorgensen, who serves as a caregiver for an adult girl with special needs, has created a free form that you can print to guide you when taking notes during telephone calls with your insurance company. She advised to ask the insurance representative for a “ticket number” and their name before conversing.

4. Call as soon as possible.

The silver lining is that most refusals, if on appeal, are overturned.

The data from Medicare Advantage published by KFF in January revealed that almost 82% of the prior refusals of the 2019 to 2023 authorization were partially or completely canceled during the appeal.

But the clock turns. Most health plans only give you six months to appeal the decision, according to the rules established in the affordable care law.

“Do not do,” advised Jorgensen, especially if you send a paper call, or any supporting document, via the American postal service. She recommends depositing quickly and at least four weeks before the deadline.

For the sake of speed, some people turn to artificial intelligence to help create customizable call letters.

5. Ask for help at your HR service.

If you get your health insurance through an employer, there is a good chance that your health plan is “self-funded” or “self-assured”. This means that your employer contracts with a health insurance company to administer social benefits, but that your employer supports the cost of your care.

Why is it important? As part of the self -funded plans, decisions on what is covered or not are finally based by your employer.

Let’s say, for example, your doctor recommended that you undergo surgery, and your insurer denied prior authorization for this, judging the “not medically necessary” procedure, a commonly used sentence. If your plan is self -funded, you can call on the human resources service at your work, because your employer is hooked for your health costs – not for the insurer.

Of course, there is no guarantee that your employer will accept to pay. But, at the very least, it is worth seeking help.

6. Find a defender.

Many states use free consumer assistance programs, available by phone or e-mail, which can help you make a call. They can explain your advantages and can intervene if your insurance company does not comply with the requirements.

Beyond that, certain non-profit advocacy groups, such as the Advocate patient Foundation, could help. On the Foundation’s website, there are advice on what to include in a letter of appeal. For those who fight against serious illnesses, foundation employees can work with you head-to-head to fight against denial.

7. Make noise.

We have already written about it. Sometimes when patients and doctors are shame on online insurers, refusals are canceled.

The same is true when patients contact the legislators. State laws regulate certain categories of health insurance and, with regard to the establishment of the police, state legislators have the power to hold responsible insurance companies.

Grounding your legislator is not guaranteed to operate, but it could be worth it.

Finally, if you want to share your experiences with a journalist, fill out this form. We would like to hear from you.