Harnessing patient power: Another approach in handling insurance disputes

Patients who deal directly with insurers are often more successful at resolving problems. But asking a patient to intervene should be a carefully considered decision.

By Pamela Lewis Dolan — Posted Feb. 5, 2007

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Mark Granoff, MD, spent more than an hour on the phone with an insurer trying to get approval for a non-formulary medication. Three separate phone calls and no headway later, he handed the proverbial baton to his patient.

Dr. Granoff, an internist and geriatrician from Los Angeles, said he generally likes to handle disputes himself. But in cases where he clearly is getting nowhere, the former medical director for Blue Cross of California knows from experience that it's the patient who holds the power to get things done. Sometimes getting the patient involved is key to getting a dispute resolved.

Insurers "are not anxious to make the patient unhappy," Dr. Granoff said. "They are the ones paying."

Getting a patient directly involved with insurance disputes can be tricky and can require some coaching from the physician. But if done at the right time and in an appropriate manner, it can pay off.

Because patients have been paying more out of pocket for their health care in recent years, some doctors feel patients are more willing to fight for benefits. And the time patients spend advocating on their own behalf is time physicians can devote back to patient care.

Kathryn Stewart, MD, MPH, a family physician and director of care management at Mt. Sinai Medical Center in Chicago, said she used to spend a lot of time on the phone advocating for patients.

"But in this day and age, it's just not practical for primary care physicians to do that anymore," Dr. Stewart said. "Doctors are increasingly pressed to see more patients, and many are having a difficult time staying out of the red."

While some have taken a proactive approach and gotten the patient involved before a dispute arises, others have found a patient's voice can be the nudge that results in a change of heart.

The people making the decisions "are human, too," said New York attorney Richard Quadrino, who has represented hundreds of doctors and patients in coverage disputes.

When to get patients involved

The choice to get a patient involved should be made judiciously, Quadrino said. "I don't know if the insurance company really wants to hear from the patient unless it's a real medical necessity. And often the doctor can speak to the medical issue."

But Dr. Stewart said having communication between the patient and the insurer can not only result in quicker resolutions to disputes in certain situations, but can also be a good line of defense if the patient is requesting a procedure that the doctor knows will not be covered.

Because the patient is the client, "it's really up to the insurance company to explain to the patient why or why not it is being covered," she said.

For example, she recently had a patient who wanted to be transferred to a hospital outside his HMO network. After a fruitless call to the insurer, she told the patient he would have to call the insurer directly if he really thought a transfer should be granted.

Jerry Bridge, president of San Diego-based Bridge Practice Management Group, encourages physicians to anticipate potential problems and have new patients sign an appeals authorization on their first visit. Having that authorization in hand will allow the practice to start a time-sensitive appeal without waiting to coordinate with the patient.

And while Quadrino thinks patient involvement should be an exception rather than a rule, he does agree physicians should anticipate which procedures will be scrutinized and take a preemptive approach when submitting those claims.

He suggests a letter from the patient describing the daily difficulties or the impact a condition has had on his or her livelihood be sent with the claim.

"Trying to overturn a decision is harder than trying to influence the decision in the first place," Quadrino said. "Psychologically, it's different."

Making patient involvement effective

The easiest and quickest way for a patient to get involved is with a phone call. While that may sound simple, patients will likely need a little coaching, Bridge said. "The best situation is where the patient and [physician] can partner up."

When Dr. Granoff urged his patient to fight for coverage of a non-formulary drug, he made sure the patient knew whom to talk to.

"I told him he needed to get the highest-ranking person up the chain," Dr. Granoff said. And because the first tier of phone answerers are generally "reading from a cookbook," patients usually have the best luck when they speak to the insurer's medical director or another doctor on duty.

"If they can get someone who knows what they are doing, then they can get somewhere," he said.

The patient should also know to record the name of every person they speak with and what they are told. If the matter is not resolved right away, some experts suggest sending these notes to the insurer via certified mail with a letter saying it will be assumed all parties agree with the content if a response is not received by a specified time.

For nonurgent matters, most experts agree the patient can skip the initial phone call and go directly to pen and paper.

The patient needs to be able to argue why a claim should be paid, Bridge said. Patients should be familiar with their health plan contracts and know what is covered. Including contract language will show the insurer the patient is informed, and using the proper codes will keep the letter as specific as possible.

But the biggest difference between a letter from the physician and one from the patient is the human element. Doctors can speak to medical issues, but only patients can describe how a condition has impacted their lives, Quadrino said. If the patient finds writing a letter to be difficult, the physicians can offer a questionnaire about symptoms and pain, then use those answers to draft a letter that can be signed and sent on the patient's behalf.

Letters should never contained "canned" content, he said. If the insurer sees the same basic letter 45 times, each signed by a different patient, it will carry less impact.

Dr. Stewart said the biggest benefit of a letter is the paper trail. Insurers are required by law to act on written correspondence.

Bridge said copies of all letters should be sent to the state insurance regulator or someone with law enforcement power.

Dr. Stewart agreed, saying she had a recent case at Mt. Sinai in which the utilization team felt the insurer wasn't meeting its obligation. She told the patient's family, "If you really want to hurt them [the insurer], this is where you go," and directed them to draft a letter to the insurer and send a copy to the state's attorney's office.

Dr. Granoff also suggests patients get their employers or unions involved.

One voice might not make a difference to an insurer, but a voice representing a significant number of policyholders will get their attention, he said. He has seen several disputes come to an immediate resolution after a call from a company's human resource director, he said.

Patients should know that dealing with insurance disputes can be tedious.

"[Insurers] have learned that if you put enough stumbling blocks in the way, [the patients] usually give up," Dr. Granoff said.

Ultimately, it's persistence and a paper trail that will lead to success.

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Share the heavy lifting

How you and your patient can successfully challenge an insurer's decision:

  • Appeal every denial. Data show appeals have a high success rate.
  • Record everything. When you call an insurer for preauthorization or verification of a benefit, make a note of the conversation and the names of people you spoke with.
  • Send all written correspondence via certified mail and keep records. Time limits can be placed on insurers. Writing things such as, "If you do not respond in five business days it will be assumed there are no disputes with the content of this mailing" can sometimes lead to quicker action.
  • If you don't get an acceptable answer, go up the chain of command. Copy the plan president with your dispute. For long-standing disputes, send copies of your correspondence to the state insurance commissioner or the state's attorney's office.
  • Get the patient involved. A heartfelt letter explaining how the patient's life would improve with a certain procedure or treatment can be compelling. If you anticipate difficulty, submit the patient's letter along with the initial claim.
  • If another physician has more expertise that speaks to the scope of the claim, include a second opinion.
  • Establish a history with the patient and ensure it is well documented. Insurers place more weight on the opinions of a physician who has an established relationship with the policyholder.
  • Get the employer or labor union involved. Experts say a complaint from an employer who is paying for a large number of insurance plans gets attention.

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The appeal of appeals

Outcomes of nearly a half million utilization review requests to two large California medical groups and data from two large California HMOs were analyzed to study coverage disputes and denials. The 2004 report from the RAND Corp. found:

  • Requests most commonly denied involved durable medical equipment.
  • Denials were more frequent among postservice requests compared with preservice.
  • Enrollees won more than half of all appeals and three-fourths of all postservice appeals.
  • Patients won nearly all appeals over emergency care.
  • There were about 3.5 appeals per 1,000 enrollees.

Here are the most common denials, and their appeal potential:

Most common denials
Claim Medical group 1 Medical group 2
Durable medical equipment 23% 15%
Emergency care 17% 16%
Preservice appeals
Reason for denial Successful appeal
Care not medically necessary 52%
Benefit not covered by plan 33%
Out-of-network provider 35%
Administrative issue 47%

Source: RAND Corp. 2004

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