Most people entering the hospital, whether they’re seeking mental health care or going to a doctor’s appointment, have more to worry about than just insurance.
Yet the system that helps pay for medical costs often becomes an overwhelming part of seeking health care — with billing, paperwork and denied claims often leaving people emotionally drained.
Those frustrations came to the surface of the national dialogue recently, after the killing of the CEO of America’s largest health insurance company, UnitedHealthcare. What followed was a swell of anger — not at the accused shooter but at insurance companies, as many people shared their own frustrations with health insurance.
Health advocates say they’ve long seen the mental health toll that dealing with insurance takes on patients.
“There’s a lot of concern about accountability,” said Joe Feldman, the CEO of Cover My Mental Health, a nonprofit that provides free advice and templates for people seeking help with denied insurance claims for mental health and substance use treatment. “Who holds insurance companies accountable for providing support and services that they’re supposed to at a very basic level? I think there’s tremendous frustration.”
Eleanor Hamburger, a Seattle-area lawyer who works on health and disability insurance cases, said consumers come into a system that’s already stacked against them. When people get denied claims, health insurance companies often obscure the policies that led to the denials. Each type of health insurance — private employment, government employment, self-funded — has different rules.
“That adds to the frustration and confusion,” she said.
Cheryl Kauffman, the founder of Seattle Patient Advocates and a physical therapist in the Seattle area, said most of her clients come to her expressing some kind of frustration about health care.
But patients can educate themselves on their plans so that they’re in a better position to push back when problems arise.
“It’s absolutely not a cure-all,” Kauffman said. But, “I think the practical stuff is actually quite powerful. It gives people some agency for things they can do.”
For those facing denied coverage, unexpected charges or just confusion with the insurance process, here are some tips to help navigate the health insurance landscape.
- 1. Know your rights and understand your plan
Patient advocates recommend that before taking any action, people should familiarize themselves with their plan and know exactly what their benefits are. Health plan summaries offer a short description of what’s covered and what’s not.
For more details, or to understand a denial for something that wasn’t clearly spelled out in the summary, consider reviewing the full policy — usually outlined in a benefits booklet or a “certificate of coverage,” and usually available on the insurance company’s online patient portal or through an employer. Consumers can search for specific scenarios or billing codes to see what their plan covers or omits.
“I think most people are not very well-informed about what their policy does and doesn’t cover,” Kauffman said. She recalled her own experience trying to get a small procedure. When the bill came, she found out her claim had been denied.
She looked up the procedure in her certificate of coverage, and found it was only covered for people who have diabetes.
“Was I disappointed, frustrated, bummed out? Certainly,” Kauffman said. “But it was a legit denial and I just had to pay the bill. But I think most people don’t take that step.”
- 2. Get help communicating with your insurance company
There are resources, free or otherwise, that can help consumers through paperwork and phone calls with insurance companies.
Some patient advocates, like Kauffman, can assist people with all aspects of the health care systems. Others focus on specific areas only, such as clinical care or billing.
Some nonprofits may also offer free advice or online resources.
Cover My Mental Health is one such service, offering people free assistance specifically for denied claims for mental health and substance use treatment. Feldman, the founder, started the website after his experiences struggling to get insurance companies to cover residential treatment for his daughter. The website offers advice for different scenarios, such as denials because something is not “medically necessary,” or getting help from your insurance company when you can’t find an in-network provider. It also provides templates for letters or phone conversations with your insurance companies, such as for filing a formal complaint.
The nonprofit Northwest Justice Project also provides free legal services and has medical-legal partnerships with various local health care providers to help people access health care.
For extreme cases, such as when someone is in crisis or can’t make decisions on their own, they may be able to authorize someone to act on their behalf, such as through a mental health advanced directive.
Hamburger, the consumer health lawyer, recommended documenting every conversation you have with your health insurance company.
“What you’re told on the phone never matters unless it’s written down,” she said. Health care plan administrators are only legally required to give you documentation if you ask for it in writing, Hamburger said.
Consumers also have a legal right to their internal files at their health insurance company. If you’re denied coverage, write a physical letter or send an email asking for all the documents that the company relied upon related to the denial, Hamburger said. Be sure to ask for a return receipt if you’re sending a physical copy, so that you have proof of delivery.
The information you get back may include internal communications about your denial.
“You’d be surprised what you find. Sometimes it’s really different than what you were told in the letter,” Hamburger said. “It might really inform the basis for the denial, and how to shape your appeal.”
Hamburger noted that while companies are legally required to provide case files upon request, the penalty for not doing so is insignificant for them — and they may not always comply.
Getting this information can help consumers appeal a claim if an insurance company denies coverage because it’s not “medically necessary.”
“Medical necessity is not a term taught in medical school or training. It’s a legal term,” Feldman said. “Clinicians are taught to do no harm, use safe and effective treatment, and apply generally accepted standards. When you have a legal standard that differs from the training the clinician has received and practices, that’s where you get into trouble.”
Knowing the criteria the insurance company used to deem treatment “not medically necessary” can help doctors write letters of support for patients to explain why they do need treatment.
- 4. Understand what you’re paying for
“I tell my clients all the time, ‘never pay the first bill,’” said Kauffman, citing a book by the same name by Marshall Allen.
Instead, Kauffman said, wait until you’ve received your explanation of benefits — a document that shows you what portion of your bill is covered by insurance, what discounts have been applied and what you’ll be charged.
If something doesn’t look right, don’t be afraid to call your insurance company and ask.
“There are so many steps in the billing and claims processing procedures, and all of them are touched by humans,” Kauffman said. “Humans make mistakes.”
Hospitals are also required to provide financial assistance for low-income patients. Known as “charity care,” the eligibility requirements were recently expanded. Nearly half of all Washingtonians could now qualify for some type of debt relief on care that is considered “medically necessary.”
The nonprofit Dollar For can also help you determine whether you’re eligible for charity care.
- 5. Take the complaint to a higher level
Most people don’t appeal denied claims. The process is cumbersome, and many people don’t have the time or energy to do so.
But while there’s conflicting data about how successful insurance appeals are, health care advocates say it may be worth it to try. Each insurance company has a different process for appeals, but will likely require a letter from the patient explaining what service they were denied, why they believe it should be covered, and any relevant details about their health condition. Supporting documents or a letter from a doctor can bolster the case. The Washington Office of the Insurance Commissioner offers some tips and example letters for how to appeal a denial.
“I don’t even appeal every denial I get, even when I think it’s wrong,” Hamburger said. “I think that’s very common, and I think health insurers count on that.”
Hamburger also suggested filing a complaint with the Office of the Insurance Commissioner — the state agency tasked with regulating insurance costs. The agency may be able to help consumers get explanations from the company about denied claims. It also tracks complaints, and may be able to investigate and fine insurers if the office finds patterns of legal violations.
Local lawmakers may also be able to get involved. A bill introduced this legislative session, House Bill 1432, aims to improve access to mental health and substance use disorder treatment. The bill seeks to make the appeals process more transparent, by requiring health insurers to make their criteria for determining claims public.
If a case must be resolved in court, Hamburger said consumers can likely find health care lawyers to represent them who work on contingency, meaning they only get paid if they win the case.
Feldman, the nonprofit founder, urged people not to give up if they hit barriers with their health insurance.
“Overcoming the conditioned response of ‘I guess we’re stuck,’” he said. “That can really make a difference.”
