When a child becomes ill or gets diagnosed with a
life-threatening disease, the last thing parents want to deal with
is denied insurance claims.
"What's most frustrating is that they have to worry about
money when they are dealing with a serious illness. It just makes
them feel like they can't do everything for their child," says Erin
Schwass, a licensed social worker in the pediatric oncology
department of Comer Children's Hospital in Chicago.
Don't despair, say Schwass and other patient
In many cases, insurance claim denials can be successfully
appealed and overturned. In states studied, 39 to 59 percent of
denied claims were overturned, according to a March 2011 report by
the U.S. Government Accountability Office.
But there are some do's and don'ts when it comes to
fighting for the care your child needs.
Before you hit the panic button, realize that technical
issues often trigger a claim denial. In fact, one in five medical
claims is processed inaccurately by insurers, according to the 2010
National Health Insurer Report Card by the American Medical
Association. Billing errors, duplicate claims or missing
information on a claim frequently led to claim denials, the GAO
"That's why it's really important to look at the reason
for the denial. It's not always something that requires an appeal.
Sometimes it's just a matter of reprocessing the claim," says Erin
Moaratty, chief of external communications for the Patient Advocate
Foundation, a Newport News, Va.-based nonprofit that provides
access-to-care services free to patients with chronic,
life-threatening or debilitating diseases. Last year, PAF
overturned 99 percent of denied claims it appealed.
Once you know the reason for denial-under the Employment
Retirement and Income Security Act, insurers must submit a letter
explaining the specific reason for denial and what your rights are
under appeal-read your health insurance contract
The AMA report cited lack of eligibility as the most
common reason for claim denial. "A lot of what we see has a
tendency to be right in the contract language itself," Moaratty
says. "The first level of appeal is often viewed based on the
Your rights in Illinois
The federal Patient Protection and Affordable Care Act
requires all individual and group health plans, including
self-insured plans, to provide an appeals process. Under the Health
Carrier External Review Act, which took effect on July 1,
2010, all Illinois residents with health insurance have the right
to an external, independent review of denied health insurance
claims. For cases that require immediate insurance approval, such
as a child facing cancer treatment, Illinois law allows for an
expedited review process, with decisions required within 72
Illinois is also one of 27 states and the District of
Columbia that mandate coverage for cancer research
Don't ignore the denial or make the mistake of thinking
you can deal with it later. Insurance plans will outline how long
you have to file an appeal.
"You don't want an opportunity where you could've
overturned it but didn't file in time," warns Moaratty.
To avoid wasting time and to limit frustration, Schwass
always advises families to ask their insurance carrier to appoint a
case manager to their claim.
"Then they have a point person within the insurance
company, so every time they call they don't have to go through some
random person on the phone," she says.
Always put any formal appeal in writing. "If you do it in
writing, you have a tracking mechanism," says Moaratty. But stick
to the facts of why the claim is being denied. "The emotional
aspect is not what's going to win the appeal," says
Whenever you can, include letters from your attending
physician, with evidence supporting the need for certain
treatments, tests or medications.
"Any peer-to-peer opportunities that could exist between
the treating doctor and the medical director of the insurance
carrier is a very effective way to appeal," says
For instance, to help patients stay on insulin monitors
and pumps that have been working well for them, Dr. Rosemary
Briars, co-program director of the Chicago Children's Diabetes
Center at La Rabida Children's Hospital, and her team often
intervene. "We have to write a letter describing the medical
necessity and the risk the patient is at if they have to do
without," she says.
Don't go it alone if you don't have to, says Moaratty. "If
parents are dealing with a child who is very ill, it may be helpful
to have an advocate because they can keep an organized
When you get a claim denial, seek outside assistance
immediately, advises Schwass, who has helped hundreds of families
navigate the insurance maze at her 10 years at Comer's.
"Parents don't have to be alone in dealing with this," she
says. "Nobody expects them to know every resource, that's why
there's social workers and case managers and people who can
Freelance journalist Rita Colorito brings you the latest health news in Chicago Parent’s Health Page.
See more of Rita's stories here.
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