Maybe you've already faced this scenario: Your health insurance company sends a letter saying it's not going to pay that last claim because the doctor was out of the plan's network or the procedure wasn't preapproved or the medication isn't in the formulary anymore.

        Now what?

        If it's a $60 office visit or the last $50 of your $500 deductible, you might be tempted to just pay the bill and forget it. But what if the denied claim is for a trip to the emergency room that ended with a stay in the hospital? What if it's for a cancer treatment?

        Consumers can fight back when the insurance company says no, experts say, and often win at least partial payment for contested claims.

Kelly Wright (standing, left), Kendra (right) and their mother Roberta. (Ernest Coleman photo) | ZOOM |

        But waging a successful battle requires organization, knowledge and, in the case of one Tristate family, persistence.

        When her insurance company refused to pay nearly $4,000 in physical therapy bills, Kendra Wright and her family spent months making phone calls, writing letters and demanding answers before they won their contest.

        The Wrights — Kendra, 40, and her mother, Roberta, 75, and sister, Kelly, 38 — requested an internal appeal of their denied claim. When they lost that round, they asked for an external appeal — sometimes called a member hearing — of the claim. They're happy with the results, despite the frustration they experienced while they were trying to get the bill straightened out.

        “It took a lot of patience, and a lot of forebearance,” Roberta Wright says. “You just have to wade through it.”

        It all started in June 2000 when Kendra Wright began physical therapy for her shoulder and back after surgery to repair old injuries. When she started getting the therapy at Spectrum Rehabilitation at Christ Hospital, a customer service clerk for UnitedHealthcare told her her policy would cover 20 visits per body part per year.

        It wasn't until she got the bill for about $4,500 from Spectrum — later amended to about $3,900 — that she learned there had been a mistake.

        What the UnitedHealthcare clerk should have told Kendra was that her policy would cover 20 visits total a year. And her coverage was based on a July-June period, not a January-December calendar year. It took several months for the Wrights to get both those pieces of information.

        Nancy Newton, regional spokeswoman for UnitedHealthcare, says the company can't comment on individual cases, but routinely gives customers information on how to appeal when a claim is denied.

        Pat Samson, a spokeswoman for HealthAlliance, which owns Spectrum Rehabilitation, says Spectrum routinely checks to make sure therapy is covered by patients' insurance and that the rehabilitation service worked with the Wright family on their appeal after the billing problem was discovered.

        Rhonda D. Orin, a Washington, D.C., attorney, has sued so many health insurance companies for not paying claims that she's written a handbook for consumers, Making Them Pay: How to Get the Most from Health Insurance and Managed Care (St. Martin's Griffin; $13.95).

        Consumers have to take the initiative for getting their claims paid, Ms. Orin says.

        “I'm trying to get across the idea that I don't know if you're the master of your fate, but you have more control over your fate than you think,” she says. “You have to get into the habit of being an activist, even if it's not a big problem. I think people let the $20, the $30 problems slide, but I'm trying to teach a philosophy that you should get into the habit of talking back to your insurance company so that if a disaster comes your way, you won't be in the learning curve.”

        Most consumer complaints aren't about $60 office visits, Ms. Orin says. They're about big-ticket items like bone marrow transplants or MRI scans during visits to the emergency room. And when someone is battling cancer or another life-threatening illness, they probably don't have the time or energy to fight their health insurance company over coverage.

        Most denial letters are written in “legalese,” Ms. Orin says, and by the time many consumers get past all the whereases, they're too confused — or too intimidated — to fight back.

        That's why it's important to know how to fight before setting foot into the ring, she says. Her advice:

        • Read your insurance policy. Know what your co-pays and deductibles are.

RESOURCES

State agencies: Call your state insurance department if you feel you've been treated unfairly or you want information about insurance coverage requirements or appeals processes:     • Indiana Commissioner of Insurance, (317) 232-2385.     • Kentucky Insurance Commissioner, (502) 564-3630.     • Ohio Director of Insurance, (800) 686-1526.     Advocacy agencies: Call these organizations for advice on how to fight your insurance company's denial of claims and for help filing an appeal or information on health care policy:     • American Association of Retired Persons (AARP), (202) 434-2277; www.aarp.org.     • Alliance for Health Reform, (202) 466-5626; www.allhealth.org.     • Center for Medicare Advocacy, (860) 456-7790; www.medicareadvocacy.org.     • Center for Patient Advocacy, (800) 846-7444; www.patientadvocacy.org.     • Consumers Union, (914) 378-2000; www.consumersunion.org.     • Families USA, (202) 628-3030; www.familiesusa.org.     • Kaiser Family Foundation, (800) 656-4533; www.kff.org.     • National Alliance for the Mentally Ill; (800) 950-6264; www.nami.org.

        • Keep track of what you've paid. If you've met your deductible, tell your insurance company — and have the paperwork to prove it.

        • Keep a copy of every check, every bill and every statement issued for every member of the family. And when your insurance company says you should be reimbursed for something within 60 days, circle the date on the calendar. If you don't have a check by that time, call the insurance company back.

        • Know what your state's “mandatory coverage” laws are. Laws vary from state to state, but most states require insurance companies to pay for things like mammograms and some cancer drugs.

        • Know what you're paying for, and what you're being paid for. There's usually a difference between what a doctor bills you directly for a procedure or office visit (the “usual and customary charge”) and the contracted rate they receive from the insurance company. When your insurance company reimburses you $30 for the office visit you paid $60 for, call them on it. Make it clear they're supposed to reimburse you the full rate, not the discounted rate they give the doctor.

        • Know your options. Almost all large plans include provisions for in-house appeals for denied claims. Thirty-eight states, including Kentucky, Ohio and Indiana, mandate external reviews for denied claims. Contact your state department of insurance for information.

        • Do your homework. When picking your insurance plan, don't automatically go with the lowest premiums or the lowest co-pay. Check to see what each plan covers.

        The Wrights faced several problems in their battle: Kendra didn't have a copy of her insurance policy and couldn't get one until her case was almost wrapped up. They were given bad information about coverage. There were billing problems and no one asked Kendra for a co-payment when she went for physical therapy or sent her a bill until March. Her billing period was based on a fiscal year, not on a calendar year, and that affected the number of visits she was allowed.

        But they went through the in-house appeal, and when that was denied, they went through the external appeal. That's when they won: The panel ruled that UnitedHealthcare had misinformed Kendra about her coverage.

        She began receiving therapy in June (the end of her coverage year), and it wasn't until November that she learned she was only supposed to receive 20 visits per year. The panel ruled that UnitedHealthcare should cover the visits through November, except for the $500 deductible Kendra's policy spelled out. And the 20 visits rule would be applied to the visits after November, with the same $500 deductible in place.

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