When Sally Knicks discovered that her health insurance provider wouldn’t cover costly, doctor-prescribed treatments for her neurological pain, she was ready to stand up and fight.
After several years of navigating conflicting decisions and changing insurance companies, she finally got the green light for treatment in January. Now, she dedicates her time and energy to assisting others who are facing similar challenges.
“I often tell people, ‘Don’t panic, this isn’t the final answer,'” said Knicks, 55, from Stateville, North Carolina.
To manage costs, most health insurance companies employ a pre-approval process. This means patients or their providers need to obtain approval before undergoing certain procedures, tests, or prescriptions.
While denials can be appealed, nearly half of those who experienced a denial in the last two years described the appeal process as somewhat or very challenging, according to a July poll from KFF, a health information nonprofit organization.
“It’s overwhelming by design,” Knicks comments, indicating that insurance companies often rely on confusion and fatigue as tactics. “That’s exactly what they want.”
The upside, she assures, is that you don’t need to be an insurance expert to achieve results. “We just need to know how to push back,” she said.
If you’re struggling with bills or complaints about care or repairs that seem to be lacking in your health, home, or car, there’s support out there.
Here are a few suggestions for tackling a previous denial of coverage:
1. Understand your insurance plan.
Is your coverage through your employer? Did you purchase it via Healthcare.gov? Or is it part of Medicare? These nuances can be tricky but they’re really important. Different categories of health insurance are governed by different institutions, each with their own prior approval requirements.
For instance, federal marketplace plans and Medicare are overseen by the U.S. Department of Health and Human Services, while employer-sponsored plans fall under the Department of Labor. Medicaid plans, managed by state agencies, are subject to both state and federal regulations.
Familiarize yourself with the specific language of your policy. Health insurance companies don’t apply uniform pre-approval rules across all plans. Ensure that your insurer is adhering to its stated rules and review the regulations at both the state and federal levels.
2. Collaborate with your provider to appeal.
Kathleen Labunch, who retired from a Philadelphia-area rehabilitation hospital in 2024, spent a large part of her career conversing with health insurance firms on behalf of her patients.
Labunch advises that before reaching out to an insurance company, patients should ask their providers to connect with a healthcare administrator or someone in the office who specializes in pre-approval appeals.
Your clinic might already be working on an appeal, which is a bonus.
“Medical staff can be your advocate,” Knicks says. “They speak the language.”
During the appeal process, you or your provider can request a “peer-to-peer” review. This allows your physician to discuss your case directly with a medical professional from the insurance company.
3. Stay organized.
Many hospitals and clinics utilize systems like MyChart to keep track of medical records and communications efficiently. Patients should also document phone calls, emails, and all correspondence related to their insurance and appeals.
Knicks emphasizes the importance of keeping everything organized, whether digitally or in print. At one point, her meticulous records revealed inconsistent information from her insurance provider. “That record saved me,” she said.
“Leave a thorough paper trail,” she advises. “Record every call, every letter, every name.”
Linda Jorgensen, who leads a nonprofit offering resources for disabled patients and their families, encourages patients to save every paper copy of communications. “If it’s not on paper, it didn’t happen,” she affirms.
Jorgensen also created a guide to assist caregivers when speaking with insurance companies, suggesting that they request the representative’s “ticket number” and names during calls.
4. Appeal promptly.
The good news is that many denials are successfully overturned upon appeal.
KFF’s data revealed that nearly 82% of prior rejections from 2019 to 2023 were either partially or fully reversed during the appeal process.
However, timing is crucial. Many health plans impose a six-month limit for appeals.
“Don’t delay,” Jorgensen advises, especially if you’re sending written appeals through traditional mail. She recommends submitting materials at least four weeks before the deadline.
To increase speed, some are utilizing AI tools to generate customizable appeal letters.
5. Reach out to HR for help.
If your health insurance comes from your employer, it’s likely either a “self-funded” or “self-insured” plan. This means that while an insurance company handles benefits, your employer ultimately bears the costs.
This distinction is significant because it means your employer has the authority to approve or deny claims.
For example, if a doctor recommends surgery that the insurance company deems “not medically necessary,” and if your plan is self-funded, you can appeal directly to your employer’s HR department.
While there’s no guarantee they will agree to pay, it’s certainly worth reaching out for assistance.
6. Seek out supportive resources.
Various states offer free Consumer Support Programs, available via phone or email, to assist you in filing appeals. They can clarify your rights and may intervene if your insurance provider isn’t complying with regulations.
Nonprofit advocacy organizations like the Patient Advocacy Foundation can also be helpful. Their website provides resources on what to include in your appeal letter, and for those faced with severe illness, they offer one-on-one support in fighting denials.
7. Make some noise.
Sometimes, patients and doctors calling out insurance companies online for their denials can lead to overturned decisions.
The same logic applies to contacting local lawmakers. State regulations govern different categories of health insurance, and state representatives can hold insurers accountable.
While reaching out to lawmakers doesn’t ensure resolution, it may be worth trying.
