Aetna under investigation: How to deal with an insurance claim denial

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Myles Ma, CPFCSenior ReporterMyles Ma, CPFC, is a senior reporter and certified personal finance counselor at Policygenius, where he covers insurance and personal finance. His expertise has been featured in The Washington Post, PBS, CNBC, CBS News, USA Today, HuffPost, Salon, Inc. Magazine, MarketWatch, and elsewhere.

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A former medical director for Aetna said under oath he denied claims without looking at patient's records, CNN reported. Dave Jones, insurance commissioner for California, launched an investigation after learning of the deposition. Jones' office is looking into how widespread the practice is within Aetna.

Aetna's official response said company medical directors review "all necessary medical information" in evaluating cases.

"While we can’t comment on the alleged actions of a former employee due to ongoing litigation, we want to be clear that our policies always have our members’ best interests in mind," the company said.

Being sick or injured is stressful enough. Worrying about whether your insurance will pay for your treatment only compounds your troubles. Here's what to do if your insurance claim is denied.

Read your policy

Former President Barack Obama's health care law requires health insurers to provide a summary of benefits and coverage to anyone who enrolls in one of their plans. Make sure to read up so you know what your policy is supposed to cover. The policy itself should say how to appeal if your claim is denied. Here's a guide to signing up for health insurance under Obamacare.

There are typically two levels in the appeal process: The first is an internal appeal conducted by the insurance company. The second is an external appeal conducted by an independent third party.

You can also reach out to your state insurance department if you have questions on the appeal process. Don't be afraid to shop around for the best health insurance option — we can help with that.

Gather your documents

If your claim is denied, you should get notice from your insurer, the National Association of Insurance Commissioners said. You should prepare a list of questions about the denial and gather documents like your policy, the summary of benefits and coverage and the denial letter. Then, contact your insurance company. The contact information should be on the back of your insurance card and the denial letter.

While you're speaking with company representatives, take notes. Get the name of the person you're talking to and the date and time of the conversation. Ask for the person's direct phone extension in case you need to reach them again.

That may be the end of it. Sometimes claims get denied because of simple errors that get cleared up with one call. But if this isn't the case, and your insurer still won't pay the claim you need to switch to mail.

Write a letter

A formal appeal usually requires you to send a letter to your insurance company asking them to reconsider the claim. Be specific in the letter about why you think it should pay your claim. Include details like why you need the procedure or medication and why your policy should cover it.

Include evidence like medical records, X-rays and lab results. You may want to ask your physician to write a letter explaining why the treatment is medically necessary. You can also ask for an expedited appeal if you or your doctor thinks the denial of your claim is life-threatening. Here's how you can get your medical records.

Keep a copy of everything you send to the insurance company.

Obama's health care law requires insurance companies to respond within certain timelines:

  • 72 hours if your claim is for urgent care

  • 30 days for treatment you haven't received yet

  • 60 days for treatment you've already received

When the insurance company responds, it should list next steps, plus a time frame for additional follow-up or appeals. They may also ask for more information.

You're also on a timeline. You must file your appeal within 180 days of receiving notice your claim was denied.

What if your appeal is denied too?

If your insurance company still won't accept your claim, you can ask for an external review. You must file a written request for an external review within 60 days of the date your insurer sends you a final decision on your appeal. The notice should include the time frame.

Insurance companies are required to participate in the external review process. Many states have an external review process. If not, the federal Department of Health and Human Services oversees the review. Your explanation of benefits or the final denial of your internal appeal should have the contact information for whoever will handle your external review.

Make sure your medical data is protected throughout this process. Here's how.

A standard external review is decided in no more than 60 days.

How to deal with a surprise medical bill

Getting a claim denied can be a huge financial blow. If all else fails, you may be stuck paying the bill. (But first, make sure you're understanding the bill. Here's an easy guide to reading a hospital bill.)

This can be a heavy lift — medical debt often leads to bankruptcy. But it doesn't have to. If you've exhausted the appeal process, there are a few things that can lighten the load.

You may be able to call the hospital or medical office and ask if you can work out a payment plan. Many providers will offer a plan interest-free, so be sure to ask. You may also get a discount if you offer to pay in cash. Here are some more ways to avoid medical debt.

If that's still too steep, you can ask the billing department for financial assistance. Non-profit hospitals have charity care departments that can help you find a way to pay your bill. Other hospitals may have financial assistance programs.

If that doesn't work, many people turn to crowdfunding websites like YouCaring and GoFundMe to get help paying unexpected medical bills.

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