Dispute Resolution

Resolve Health Insurance Disputes/Appeal Decisions

What is this service?
Filing an appeal or grievance is the formal way to ask a health insurer to reconsider a decision it has made.  Each insurer, including Medicare, has its own appeals process.   Typically, a decision can be appealed several times, first to reviewers inside and then outside the health insurance company.  Smart Health Decisions helps the consumer follow the steps necessary to appeal a health insurer’s decision.  This includes offering expert advice about which decisions to appeal, preparing a persuasive argument, requesting and collecting supporting documentation and expert opinion, completing required paperwork, and attending meetings with your insurer.  We also help consumers request “coverage determinations” (a review of specific services your health plan will and will not cover) and “coverage exceptions” (your request to receive non-standard coverage from your insurer). 

How do consumers benefit from this service?
When a health insurer makes a decision that adversely impacts you, you can take constructive action by asking the health insurer to reconsider it.  Fighting the health insurance bureaucracy can be exhausting, and winning may seem like a long shot.  Fortunately, people who are persistent often win.  The odds are in your favor the decision will be changed, possibly saving you money and providing you access to the care you need.  Rand Corporation, a notable research organization, found consumers who appealed denied claims were successful in getting reimbursed in more than half the cases.  Yet only a small fraction of healthcare consumers appeal health insurer decisions.  

When should healthcare consumers use this service?
You should consider appealing an insurer’s decision right away, as the decision may impact your health and usually there are time limits for filing appeals.   If your physician judges the effects of a decision made by your insurer to significantly increase the risk to your health, your appeal is urgent.  You and your physician should call your insurer right away.  After, contact Smart Health Decisions if you want additional assistance.

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