Health care: Fighting denied claims

NEW YORK (CNNMoney.com) -- If your health insurer refuses to reimburse you for a claim, you're not alone. Denial of health care claims happens all the time. But we'll tell you how you can fight back against your insurer to get the coverage you deserve.

To avoid having a health insurance claim denied in the first place, scrutinize your copy. It's more important than ever to know what exactly is covered under your insurance policy.

That's because there are more caps now on how much insurers are willing to give you. There are new limitations placed on how much coverage you'll get per doctor visit, per calendar year and lifetime maximums.

"Access is beginning to shrink," says Beth Darnley of the Patient Advocate Foundation. And make sure your doctor is on the same page.

Before you go through a procedure - remind your doctor what is covered and what is not. With so many patients, doctors may not remember the particulars of your plan.

Call the customer service number to find out why your claim was rejected. Sometimes a denied claim is nothing but an administrative error. Out of the 39,000 cases that the Patient Advocate Foundation has worked on this year, about half were errors due to coding and billing errors.

You have the right to request a formal review by the insurer. Send a letter by certified mail. Make sure you do it quickly. Some plans only give you 30-60 days to file an appeal. Make sure you include the description of the service, why the service should be covered and any recommendations and referrals from your doctor that explain why treatment should be covered.

It could take anywhere from 60 days to six months to get your appeal finally resolved, according to Darnley. To look at examples of appeals letters, go to patientadvocate.org.

Some states have an ombudsman who can help guide you through the process. Your state's department of insurance will be able to tell you exactly how much assistance they can provide.

Most states have set up independent medical review boards to hear appeals. These review boards consist of physicians who review individual cases and insurance policies to determine what coverage should have been received.

To find out who to contact in your state, go to the Kaiser Family Foundation's Web sites at statehealthfacts.kff.org. You will also want to file a complaint about the insurer at your state's department of insurance.

You can also enlist the help of advocates. Some advocates specialize in insurance issues and can help you settle your dispute.

To find one in your area, go to the Patient Advocate Foundation at www.Patientadvocate.org. You can also check out Healthcare Advocates Inc. at healthcareadvocates.com.

Until your dispute is resolved, your credit score should not be jeopardized at all. If you have collection agencies coming after you, make sure you send a copy of the appeals letter to the collections agency and ask for a hiatus until the matter is resolved. You should also call the insurance company and tell them to call off the collections process.