Sample Appeal Letters for Medical Claim Denials

TABLE OF CONTENTS

How To Create An Effective Medical Appeal Letter For Hospitals?

One of the most significant challenges hospitals and other healthcare organisations face with their cash flow is medical claim denials. Healthcare organisations like hospitals must use the medical appeal letter to save themselves from late payments and interference in cash flow. Here, we discuss everything you need to know about creating an effective appeal letter for your organisation.

What Is A Medical Appeal Letter?

A medical appeal letter requests the health insurance company to review its decision denying a benefit of payment to a patient. The patient can send the medical appeal to insurance companies, or the healthcare provider or hospital can send it on their behalf. 

There are several reasons why an insurance company may deny the claim of one of your patients. But not all of them concern your healthcare organisation. Sometimes the claim denial could be because of an issue from the patient’s side. You can use the medical appeal letter to clarify things from your end.

Moreover, if an insurance provider denies the claim, the policyholder has a right to challenge the insurance provider’s decision. Suppose the policy provider rejects the medical appeal letter you send. In that case, your patients can get an independent assessment or seek the services of a Financial Ombudsman Service.

Why Does An Insurance Company Refuse The Claim Of Your Patients?

As mentioned above, an insurance provider may deny the claim of your patients for several reasons. You must understand the reason for policy denial to draft an effective reconsideration sample appeal letter for medical claim denial.

Insurance providers can not reject the medical claim of your patients without sufficient reasons. The insurer must specify the exact reason for refusing the patient’s claim. Hence, the healthcare service provider or patient must check the policy details carefully before sending the medical appeal letter to the insurer.

There are some common reasons or situations the insurer may highlight for denying your patient’s insurance claim. Suppose the reason for the claim denial is legitimate. In that case, there is no point in sending the medical appeal letter to the insurer. 

Following are the situations when an insurance provider can deny the medical claim of your patients.

Policy Is Not Active During The Insurance Claims

One of the common reasons why the insurance provider may deny your patient’s claim is because the policy was not active at the insurance claim. It is best to check the policy’s validity before sending the medical appeal letter on behalf of the patient.

Furnishing Wrong Or Untrue Information During Insurance Application

The policy provider may deny the claim to your patients is that they believe the patient furnished wrong or untrue information. It may be a misunderstanding, and as the patient’s healthcare provider, you may be able to help. For instance, the patient’s medical files can help clarify the situation, and you can highlight them in the medical appeal letter you send.

The insurer can deny the claim if they think your patient failed to disclose important information, such as a pre-existing medical condition. If the patient took the diagnosis later, your medical documents could prove it. In such cases, you can highlight the same in your medical appeal letter to the insurance provider.

Note: The insurance provider makes a policy invalid if the patient took out/renewed/modified the insurance before 6 April 2013.

Deliberately/Carelessly Withholding Information

Your patient’s policy claim can face rejection if they withhold information from the insurance provider intentionally or carelessly. 

But the insurer’s assessment may not be accurate, and sometimes the patient’s healthcare information can prove that. 

In that case, you can send the medical appeal letter explaining the situation on the patient’s behalf.

The Healthcare Service Not Covered Under The Policy

Another reason for policy claim denial of your patients could be that the healthcare service or item is not eligible under the patient’s plan. For example, many healthcare policies do not cover cosmetic healthcare treatments. You must ensure the patient’s policy covers your healthcare service before sending a medical appeal letter to the insurers.

Exclusion Clause In The Policy

Similar to the scenario we discussed above, there are situations when the insurer adds special clauses to the policy. The insurance service provider may include specific conditions that need clarification. Make it a point to check out the exclusion clause in your patient’s policy before sending the insurance appeal letter on the customer’s behalf.

Missing Premium Installments

Insurance companies deny a patient’s claim due to missing or irregular premium instalments. You cannot do much if the patient refuses to pay their policy instalments after receiving the insurance appeal letter.

In such cases, sending a letter an appeal letter can hardly do any good. It is best to let the patient negotiate with the insurer and not interfere with their interactions.

Not Informing Change In Circumstances

The insurance company can deny your patients’ healthcare claim if they fail to inform the insurer about their change in circumstances. The circumstantial modifications of the patient may include their health condition. In that case, your healthcare organisation can help them by sending a medical appeal letter on the patient’s behalf.

Not Following The Appropriate Policy Claim Process

Sometimes, the insurance provider may only accept the claim of your patients if they follow the appropriate policy claim process. You must send the insurance appeal letter if it involves your healthcare organisation.

Not Adhering To Policy Conditions

If the patient does not adhere to the policy condition, the insurer may deny your patient’s policy. Make sure you ask the patient to check if there was any issue with the same. Check if the policy condition refers to a policy condition that involves the healthcare organisation. If yes, send a medical appeal letter detailing the issue on the patient’s behalf.

Exaggerating The Claim

One of the common reasons insurers give for denying your patient’s policy claim is exaggerating the claim. As the patient’s healthcare provider, you can authoritatively say there is no exaggeration and attach the necessary medical documents as proof. However, check that the patient’s claim is correct before sending the insurance appeal letter from your healthcare organisation.

How To Write An Effective Medical Appeal Letter On Your Patient's Behalf?

Writing an effective medical appeal letter on your patient’s behalf takes work. Your letter should convey all the essential details to approve the patient’s policy claim. But there are several steps you can take to speed the process up. 

Here is how you can write an effective medical or insurance appeal letter for your patients.

#1 Use A Medical Appeal Letter Template To Save Time

Time is critical when sending your medical appeal letter to an insurance provider. Your medical payment is already late because the insurer denied your patient’s claim. The sooner you can appeal, the sooner the patient’s claim gets processed. 

Additionally, processing the insurance appeal letter can also take up the time of your healthcare professionals. Your healthcare professional could use the additional to serve more patients. An appeal letter template is the best way to minimise the time for sending medical appeals.

Using a medical appeal letter sample or template can save time in sending the letters. But you can speed it up significantly by using an automated direct mail system like PostGrid. It allows you to personalise your appeal letters and bulk mail them quickly. 

Healthcare organisations that deal with many patients can benefit significantly from automation. It significantly reduces your workload and ensures the accurate and timely delivery of your insurance appeal letter to the insurer.

#2 Enhance The Professionalism Of The Letter With Branding

Branding often takes the backseat in healthcare communication. Sending a medical appeal letter is an ideal opportunity for you to correct this mistake. Often the weight of the doctor’s Name or your healthcare organisation is enough to give legitimacy to your letter.

We are not saying that your letter will get any concession by providing the branding on your healthcare letters. But it does allow you to work on your letterhead, which you can use on every healthcare communication from your organisation. But you must acknowledge that branding makes your medical appeal letter more professional.

By incorporating your branding into the insurance appeal letter, you can switch up the whole dynamic of the letter. Moreover, the branding will likely resonate with the recipients over time and positively impact your healthcare letters.

#3 Save Your Records And Tracking Information

It is essential to keep a record of every medical appeal letter you send on behalf of your patients. You must also keep records of the tracking information and any documents you attach to the letter. If you are using a manual process to send your healthcare letters, this is quite challenging and prone to errors.

Ideally, your records should include a copy of the letter you send, the time/Date of when you send it, and the Date it is delivered. Using an automated system like PostGrid for healthcare makes it significantly easier to keep the records of every insurance appeal letter you send. 

PostGrid offers an easy-to-use dashboard from where you can quickly access all your past mailers. You can also provide a brief description to make your mailers easily identifiable when sending the letter. Tools like PostGrid is the best way to keep track of every medical appeal letter you send.

You can sign up on PostGrid’s web interface for free, check out the tool, and see how it can make your communication more convenient.

#4 Insurance Provider Form For Electronic Submission

Several insurance providers facilitate the electronic submission of documents, including your medical appeal letter. But there is a catch with the electronic submission for claim appeals. 

You must use only the form that the insurer provides. The electronic form from the insurance company also follows a template format to process them faster and more efficiently. Another thing worth noting is that these electronic forms have proper branding, which enables you to ascertain their validity. 

Using the electronic form may seem like the best option, but that’s not always the best option for your healthcare organisation. You have patients from different strata using different insurance service providers, and not all of them may offer electronic form submissions. Healthcare organisations can easily bulk-mail their insurance appeal letter using a tool like PostGrid.

With an automated solution like PostGrid, you can quickly send all your appeal letters. Moreover, you can use the same template for a specific medical appeal letter regardless of the insurance provider.

Hospital Appeal Letter Sample

[Date]

[Name]

[Insurance Company Name]

[Address]

[City, State, and Postal Code]

Re: [Policy Holder/Patient Name]

       [Type of Coverage]

       [Policy number/group number]

Dear Madam/Sir,

I am writing this letter to appeal your decision to deny the policy claim of [Name of medical service/procedure/treatment] after [policy holder/patient Name] ‘s surgery.

I want to inform you that [policy holder/patient Name] ‘s physician strongly suggests [Name of medical service/procedure/treatment]. It is the best option for their present physical condition.

You should also note that the requested [Name of medical service/procedure/treatment] is covered under [relevant laws supporting the case].

The following documents are attached to the letter for your scrutiny:

• The treatment plan from Dr. [doctor’s Name] for [policy holder/patient name].
• Supporting letter from Dr. [doctor’s Name] outlining the necessity for [Name of medical service/procedure/treatment].
• Copies of relevant laws and regulations associated with the medical claim.

Please review this appeal on behalf of [policyholder/patient name]. You may contact me at [phone number/email address] if you need additional information. I look forward to hearing from you.

Sincerely, 

[Your Name] 

[Your Address and phone number]

What Is The Best Way To Send Your Medical Appeal Letter?

The best way to send your medical appeal letter in bulk to insurance providers and track them is to use automation. Advanced solutions like PostGrid enable you to quickly and easily send your letters within minutes and even personalise them the way you want.

PostGrid offers robust direct mail automation software which can connect directly with your website. You can use PostGrid’s direct mail API and integrate it with your CRM solution for easy personalisation. As a result, printing and mailing the medical appeal letter for your organisation becomes significantly easier.

That’s not all. You can also use PostGrid’s web interface to send your bulk mail. All you need is a CSV file containing all the contact details of your recipients, and the system takes care of the rest. Another advantage of using PostGrid for sending your insurance appeal letter is that it lets you access bulk mail discounts from the Royal Mail.

You can use PostGrid’s direct mail automation to streamline all your postal communications and run advanced direct mail marketing campaigns. Besides accurately sending a medical appeal letter for your healthcare organisation, it can help you with the following.

• Printing and mailing patient statements.
• Manage the templates of all your letters.
• Effectively track your workflow and reporting.
• And more.

Talk to our experts to streamline your healthcare communications and efficiently send the medical appeal letter for your organisation!

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