Friday, February 05, 2010

Your health insurance company turned down your claim? DON'T give up!

Fighting Denied Claims Requires Perseverance

Peter DaSilva for The New York Times

Maria Carr does Pilates as part of therapy after arthroscopic surgery on her hip last year. Her insurance company initially refused to cover the operation, but relented on appeal.

Published: February 5, 2010

Maria Carr, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.

Her doctor told Ms. Carr he had successfully performed this procedure for eight other United Health patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.

“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.

Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.

Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.

But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.

“I decided I would fight,” she said. “After all, what did I have to lose?”

Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.

The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.

The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.

UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.

“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”

Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company now rethinking things once again because of "the changing landscape of medical literature" about the procedure.

Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.

Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement.

Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.

Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.

But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.

“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”

Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.

READ YOUR POLICY Always check your policy carefully before you undergo treatment.

Many denials are made because the policy specifically excludes coverage of a certain treatment, procedure or medicine, Ms. Praeger said. When it is spelled out that something specific is not covered, an appeal will not work.

TAKE YOUR TIME When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.

Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.

Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.

Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk. )

Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.

DO RESEARCH Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.

Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.

Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.

You can find abstracts of many articles free on, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.

Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.

You also must prove the medical necessity of a treatment, especially if it is considered experimental.

Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.

For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.

Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.

GO THE DISTANCE Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.

If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.

In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.

Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.

GET HELP Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.

Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.

You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.

Thursday, February 04, 2010

CORE meeting scheduled for February 18, 2010

From CORE, February 3, 2010
CORE (Concerned Ohio Retired Educators) will hold its February meeting on Thursday, February 18th at the STRS building at 275 East Broad Street in Columbus. Parking is free in the STRS parking garage behind the building. We encourage you to also attend the STRS Board meeting which usually begins around 9:00 a.m. on Thursday in the meeting room on the 6th floor but this beginning time varies from month to month. For this reason, we suggest you check with the STRS website ( to confirm the time. The STRS Board meetings usually include Friday as well as Thursday so you might want to check on this too.
Remember that CORE meeting attendees usually leave the STRS meeting around 11:30 on Thursday in order to get lunch in the cafeteria room (behind the Sublett Room) on the second floor of the STRS building where the CORE meeting will begin promptly at 11:45.
If you have suggestions for the February CORE meeting agenda, please send a reply to John Curry at so that he can relay this information to CORE President, Dave Parshall.
Copies of the media letter, recently written by a CORE committee, will be available for distribution at the February CORE meeting. Members can use this media letter in writing letters to the editor of newspapers in response to the recent criticism of public pensions. Also at the Feb. meeting, members can pick up copies of petitions for candidates for the upcoming Spring STRS Board elections. CORE attendees at this February 18th meeting will be deciding the candidates which CORE will support for this election. Please join us for this most important endorsement decision-making. We need your input. The committee that attended the CORE/Nehf meeting on February 8th will also be reporting.

Why? Because they can!

From John Curry, February 3, 2010
Below is a letter to the editor in the Akron Beacon Journal. I find it pleasant to see a letter from someone who understands the present and who doesn't have the selfish mindset of "I got mine and the hell with anyone else," isn't it?
Akron Beacon Journal, February 3, 2010
Health-care reform – now
I am employed, have health insurance and my wife and I are fortunate to have paid off our home. I am thankful, but also feel sadness and concern for those who have been affected by this recession. Many have lost their homes, insurance, incomes and life savings. Many families have been broken by mounting debt. Health-care reform must come soon.
Meanwhile, the ever-skyrocketing costs of health insurance and health care, coupled with diminishing insurance coverage, are starting to take a toll.
My wife and I are getting to the age where health is becoming an issue, and we are to the point where we cannot afford to use it. We feel we have no choice but to drop doctors and cancel tests. With deductibles and co-pays, the bills associated with doctor and hospital visits and, as in my case, specialized medical procedures, I am quickly sinking into a sea of medical debt.
Everyone wants their money now, if not sooner, and with multiple bills from different doctors and hospitals, we are being stretched to the limit.
Reforming health care will not only help people who need to be insured, but it will also ease the burden on the many who are not using their insurance to get health care because they just can't afford to.
Many who are still fortunate to have jobs have had to endure cutbacks in hours, wage freezes or reductions while everything else keeps getting more expensive. They do not qualify for any kind of assistance, while health-care conglomerates are lining their pockets on the failing health of what is left of the middle-class.
Our government is being fed millions to look the other way while these conglomerates monopolize the health insurance industry. With the U.S. Supreme Court's decision to remove restrictions on campaign contributions, they will be able to dictate legislation and, in essence, own our government.
The more the insurance companies charge us, the less they do for us. Why? Because they can. The biggest opposition to reform in our government comes from those who have the most to lose (financially). I think our representatives have forgotten that the reason they are in office is to serve us, and that is the biggest tragedy of all.
Ruben De La Rosa

Tuesday, February 02, 2010

Laura Ecklar responds to Tom Curtis re: 35/88 rule

From Laura Ecklar, February 1, 2010
Subject: Response to E-Mail
Good afternoon, Mr. Curtis. I am responding on behalf of Mr. Slater regarding your recent e-mail. Below, I have included a response to questions that we have received in the past about the 35-year benefit. This excerpt appeared in the August 2009 “Update From STRS Ohio” that was sent out via our e-mail news service and posted on our Web site. (The complete newsletter can be found on our Web site.) As you requested, I am also mailing to you a copy of the July 1, 2009, actuarial valuation conducted by PricewaterhouseCoopers. References to “accrued actuarial pension liabilities” represent the present value of future payments related to benefits for both active and retired members and are based on actuarial assumptions about the future. At the June 2009 board meeting, Mr. Slater noted that if the 35-year enhanced benefit did not exist, the accrued actuarial pension liability would be reduced by approximately $940 million as of July 1, 2008. As you know, the Retirement Board’s proposed pension plan changes call for the elimination of the 35-year enhanced benefit. I hope this information is of value to you.
Perception: If STRS Ohio had never offered the enhanced 35-year benefit, these changes wouldn’t be necessary.
Fact: The 35-year benefit has contributed to increased unfunded liabilities, but so have the other components of S.B. 190 that included changes to the pension formula for active teachers; recalculation of the base benefit for many retirees; and a one-time increase for all benefit recipients who needed a raise to restore their benefit to at least 85% of its original purchasing power.
Over time, there have been a number of factors that have impacted funding for pension benefits — not just S.B. 190. These include other improvements to the benefit formula and to various groups of retirees; more than $711 million in “13th checks”; allocations of more than $5.4 billion to the separate health care fund; and legislation setting the COLA at 3% in 2002. Increased life expectancy among STRS Ohio members and lower-than-expected payroll growth among active teachers have also had an impact.
To address these growing liabilities, STRS Ohio took several steps over the years, including increasing members’ contributions; lowering the annual interest rate paid on member withdrawals; stopping the 13th check; decreasing the amount of employer contributions put into the health care fund; reducing the match on reemployed retirees’ lump-sum payments or monthly annuity benefits; and adjusting investment asset allocations and accompanying expected returns.
Even with these changes, the funding period for the pension fund stood at 41.2 years on July 1, 2008. This means that based on the value of investment assets at that time, we expected to pay off all unfunded liabilities over the next 41 years by achieving an 8% annual rate of return and meeting all other actuarial assumptions. However, due to the recession, the market value of our investment assets declined by about $24 billion over the past two fiscal years. As a result, STRS Ohio’s unfunded liability almost doubled in just one year and the funding period now stands at “infinity.” Much more significant changes are needed to enable STRS Ohio to meet its funding challenge.
From Tom Curtis, January 29, 2010
Subject: 012910 Re 35 Year Rule Cost To STRS
Hello Fellow Stakeholders,
I received the following comment after my letter to Rep Wachtmann. I have written Bob Slater twice, asking for clarification, but have received no response to date.
Consequently, can any of you verify my comment, that the 35-year rule has cost the STRS 1 billion to date?
In the interest of accuracy, the 35 year enhanced benefits have not "cost the STRS $1 billion to date" as you stated in your letter to Rep. Wachtmann. What Bob Slater reported was that IF nothing was done, over the next thirty years those additional benefits would cost the system around $1 billion. (To put it in perspective, if we don't get the other changes we recommended to the Legislature, our unfunded liability would grow from our present $38 billion figure to around $80 billion.) The realization that STRS mortality assumptions were too high and increasing HC costs were the primary reasons those 35 year benefits no longer fit the "break-even" status that was believed to be the case when the changes were proposed in the 1990's. The view that those benefit enhancements did not add to the unfunded liability was reaffirmed by the Board's actuary (Buck Consultants) in 2005.
Or, do you agree with the statements above?
Tom Curtis

RH Jones: A letter to STRS retired educator board reps

From RH Jones, February 2, 2010
Subject: An open e-mail to OH STRS retired educator board reps
To both OH STRS retired reps and all retired educators:
Re: OH STRS board retiree representatives are honor bound to represent all of us retired educators!
The short-term economic needs of current retired educators are paramount, especially for those of us who have been retired over 20-years. Please remember that we are amortized. Our needs are to end cuts (perhaps illegal) to our deferred compensation, HC/Rx, flat 3% COLA, death payments, our any other hidden desires of STRS board members may have to reduce current retiree economic status. We have already become the victims of diminished economic returns such as the take away out of the general fund of the 4% STRS HC/Rx financing down to only1%. Taking away spousal and dependent HC/Rx was a particularly insensitive and inappropriate -- Retired reps are the guardians of retired educators, and must do so enthusiastically.
Concerning the long-term financial health of the STRS. I am confident that: With the modest increased infusion of employer/employee contributions, passed in the Ohio legislature by honorable and distinguished lawmakers, partnered with the compassion of both retired and active STRS board members; and, with all the STRS managers and investment staff, who know their jobs, will grow forward the new “seed” funds. For if this legislation is not passed, causing the STRS not being able to respond to their future economic needs, please remember that we are amortized. Without passage, what incentive would educators have to pay into a retirement system, if they know cuts will be made in their deferred compensations?
However, with the infusion of the new legislated funding, certainly the self-motivation is there for STRS associates to make sure that the STRS is healthy, far into the future, coupled with that of the STRS retired educator stakeholders, their economic status in the OPERS retirement deferred compensation, 3% COLA and HC/Rx will, therefore, be maintained now and into their retirement. For without the STRS employee payments into OPERS, OPERS will also be severely financially impacted, as well as the STRS. Associates now have the use of the new and faster computer equipment. They most certainly enjoy a great work environment – in the form of the outstanding building and an attached parking garage offered free to them. Because of all the factors above, one can see that investment production is, therefore, achievable.
I, too, understand that their has been an increase in the longevity of retired educators, especially female retirees, but that should not be a problem due to the fact that present educators, both female and male, are today earning far more compensation for their professional vocation than we. Because of it, they are electing on their own to work past the traditional 30-year retirement goal. Employed, today, they have better heath health care, including eye/dental/hearing and structured preventative health measures (such as no-cost admission to exercise, gymnasium/ swimming clinics.). Actives, at the moment, have much to lose by retiring. Also, currently working here in Ohio, in more and more new and air-conditioned buildings, along with legislated lower class sizes, and the use of teaching assistants, serves to attract professional educators to extend their work years.
It is not my intention to pit the retired educator with those educators (dialectics) who are still actively employed, but please remember that we are amortized. Currently, actives outnumber retired reps on the Board and for that reason, if no other, retired reps need to see to it (as did our Dr. Dennis Leone who was a great retired rep) not only to keep our retiree-deferred compensations, but also to improve on them.
This is my opinion and a report of the facts in maintaining and improving retired educators’ retirement system. It is not meant be pension envy, or to criticize anyone, but to teach.
Robert H. Jones, retired teacher OH STRS member

Monday, February 01, 2010

CORE meeting scheduled for Thursday, February 18, 2010
Click here for details.

Sunday, January 31, 2010

Thank you, Rae, from Clayton!

From John Curry, January 31, 2010
Consider the whole picture before getting angry about public pensions
Dayton Daily News, January 25, 2010
I see that “police, fire, teachers seeking pension increases” is front-page news (“Pension fight has makings of a war,” Jan. 3). Yes, the state’s public pension systems are having financial issues and taxpayers may be asked to help with the solution, but rest assured that the retirees are facing drastic changes and decreases in many benefits.
While this news is certainly cause for concern, I hope citizens are more concerned by the news on the front page of the business section, “Hospital CEOs face pay freezes amid recession.” Please consider the fairness of skyrocketing health-care costs, coupled with hospital CEOs earning million-dollar salaries and still taking bonuses, and a Congress that keeps voting themselves pay raises before directing your ire at people who have spent their lives protecting you, rescuing you and teaching your children.
Rae Voice
Larry KehresMount Union Collge
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