How Patient Advocates Help with Denied Claims & Appeals

Getting a medical claim denied can feel overwhelming. You're likely dealing with health issues while facing a mountain of confusing paperwork and insurance terminology. This is where patient advocates come in.

What Are Patient Advocates and Why Might You Need One?

Patient advocates are professionals who help people navigate the healthcare system. When it comes to denied claims and appeals, they're your personal guide and champion.

Types of Patient Advocates

Patient advocates come in several forms:

• Hospital-based advocates: Employed by healthcare facilities to help resolve issues between patients, providers, and insurers.
• Independent advocates: Private professionals hired directly by patients.
• Insurance-based advocates: Work for your insurance company to help resolve issues.
• Nonprofit organization advocates: Provide free or reduced-cost advocacy services.

Common Reasons Insurance Claims Get Denied

Understanding why claims are denied is the first step toward a successful appeal. The most common reasons for claim denials include:

• Missing or incorrect information on claim forms
• Services deemed not medically necessary by the insurer
• Out-of-network providers used without proper authorization
• Pre-authorization requirements not met
• Coding errors or mismatches between diagnosis and treatment

Red Flags That Signal You Might Need Help

Consider seeking advocacy help if:

• You've received a denial for expensive or essential treatment
• Your condition is complex or rare
• You're too ill to handle the appeal process yourself
• You've already attempted an appeal without success
• There are technical medical or coding issues involved
• You're facing tight deadlines

How Patient Advocates Help With Denied Claims

There are many ways patient advocates can help with denied claims:

Explaining Your Benefits and Coverage

Insurance policies are notoriously difficult to understand. Patient advocates can:

• Translate insurance jargon into plain language
• Clarify what is and isn't covered by your specific plan
• Explain how deductibles, copays, and out-of-pocket maximums affect your situation

Gathering and Organizing Medical Records

Medical records are crucial evidence in appeals. Advocates help by:

• Requesting complete records from all relevant providers
• Organizing documents in the most effective order for review
• Ensuring records clearly support the medical necessity of treatment
• Identifying any gaps in documentation that need to be filled

Preparing and Filing Appeals

The appeals process has strict timelines and requirements. According to the Centers for Medicare & Medicaid Services, you typically have 180 days to file an appeal for denied claims, but this varies by insurer and plan type.

A patient advocate will:

• Draft appeal letters that address the specific reason for denial
• Include relevant medical evidence and supporting documentation
• Cite applicable laws or insurance policy provisions
• Ensure appeals are filed within required timeframes
• Track the status of appeals and follow up as needed

Communicating with Providers and Insurers

Effective communication is essential for successful appeals. Advocates serve as intermediaries who:

• Speak with medical billing departments about coding issues
• Consult with healthcare providers to get supporting statements
• Negotiate directly with insurance representatives
• Document all communications for the record

The Patient Advocacy Process for Denied Claims

It’s important to understand the steps for denied claims.

Step 1: Review and Understand the Denial

Every denial notice should include a reason for the denial. Your advocate will help you understand exactly why your claim was rejected and identify the best approach for appeal.

Step 2: Gather Evidence

This critical step involves collecting:

• Complete medical records
• Letters from treating physicians explaining medical necessity
• Relevant scientific studies supporting the treatment
• Insurance policy documents

Step 3: Develop an Appeal Strategy

Different types of denials require different approaches:

• Medical necessity denials require strong clinical evidence
• Network issues may need documentation of why an out-of-network provider was necessary
• Coding errors require corrected billing information

Step 4: Submit the Appeal and Follow Up

Your advocate will:

• Submit all required documentation before deadlines
• Request confirmation of receipt
• Follow up regularly on the status
• Prepare for multiple levels of appeal if necessary

Medicare-Specific Appeals Process

For Medicare beneficiaries, the appeals process has five distinct levels, each with its own requirements and timeframes. Understanding this process is crucial for successful navigation.

Level 1: Redetermination by the Medicare Administrative Contractor

The first level involves submitting a simple form (CMS-20027) requesting redetermination within 120 days of receiving the Medicare Summary Notice. This review is conducted by Medicare staff who were not involved in the original decision.

Your advocate will ensure the form includes all necessary information and is accompanied by any relevant medical records, doctor's statements, or other evidence supporting your case.

This level has a mandatory 60-day decision timeframe, though decisions often come sooner.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

If your redetermination is denied, your advocate will help you escalate to a reconsideration by a QIC. This must be filed within 180 days of receiving the redetermination notice, using form CMS-20033.

The QIC is completely independent from Medicare and brings fresh eyes to your case.

This level involves a more thorough review by healthcare professionals. Your advocate will ensure all new evidence is submitted at this stage, as introducing new evidence later becomes much more difficult.

Reconsideration decisions typically take about 60 days, and approximately 15% of appeals are resolved favorably at this level.

Level 3: Hearing Before an Administrative Law Judge (ALJ)

If your reconsideration is denied and the amount in dispute meets the minimum threshold (approximately $180 in 2025, adjusted annually), your case can be escalated to an ALJ hearing.

This hearing is typically conducted by phone, though in-person hearings can be requested.

Your advocate will prepare you for questioning and will often attend the hearing with you to provide support and clarification as needed.

The ALJ level is particularly important as it's the first opportunity to present your case verbally to a decision-maker. About 28% of appeals that reach this level are successful, according to recent Medicare appeals data.

Level 4: Review by the Medicare Appeals Council

If the ALJ decision is unfavorable, your advocate can help you request a review by the Medicare Appeals Council. This must be done within 60 days of receiving the ALJ decision.

The Council reviews the entire case record but rarely conducts new hearings. Your advocate will craft a written request that clearly identifies the specific issues and findings you disagree with and why.

This level has no statutory timeframe for decisions and can sometimes take several months to resolve.

Level 5: Judicial Review in Federal District Court

The final level of appeal is a lawsuit filed in Federal District Court. This option is only available if the amount in dispute meets a minimum threshold (approximately $1,800 in 2025).

While patient advocates are not typically attorneys, many work closely with healthcare attorneys who can take over at this stage if needed. Your advocate can help gather and organize all documents needed for this legal process.

Though only about 1% of Medicare appeals reach this level, those that do have a significant success rate of around 40%, particularly when well-documented and professionally presented.

Finding and Hiring a Patient Advocate

Finding the right patient advocate is crucial for navigating the complex world of insurance appeals.

Where to Look for Advocates

Hospital Patient Services Departments: Most hospitals employ patient advocates or patient representatives who can help with in-house billing issues and insurance claims. These services are typically free to patients who receive care at the facility.

Contact the hospital's patient services department directly and ask about their advocacy services. These advocates have the advantage of direct access to your medical records and billing information, making them particularly effective for hospital-related claims.

State Insurance Departments: Each state has an insurance department that provides consumer assistance. Many state insurance departments have expanded their advocacy services in response to increasing claim denials.

These departments often offer free guidance and can direct you to state-sponsored advocacy programs. Some states, like California, New York, and Massachusetts, have particularly robust consumer assistance programs that include dedicated health insurance advocates.

Professional Organizations: Several professional organizations maintain searchable databases of qualified patient advocates:

• The Alliance of Professional Health Advocates (APHA) offers a directory of private advocates searchable by location and specialization
• The National Association of Healthcare Advocacy (NAHAC) maintains a directory of certified advocates who have met specific educational and ethical standards
• The Patient Advocate Certification Board provides a list of board-certified patient advocates who have passed rigorous examinations

These directories allow you to filter advocates based on expertise in insurance appeals, Medicare knowledge, or experience with specific medical conditions.

Nonprofit Organizations: Several nonprofits offer free advocacy services for qualifying patients:

• The Patient Advocate Foundation provides case management and assistance for patients with chronic, debilitating, or life-threatening conditions
• The Medicare Rights Center specializes in Medicare-related appeals and issues
• Disease-specific organizations like the American Cancer Society, American Heart Association, and National Multiple Sclerosis Society often offer specialized advocacy services for patients with those conditions

Many of these organizations prioritize cases based on financial need, diagnosis, or other qualifying factors, so be prepared to provide documentation of your situation.

Self-Advocacy Tips and Techniques

You can improve your chances of a successful appeal:

Documentation Best Practices

• Keep a log of all phone conversations (date, time, representative name, what was discussed)
• Send all important communications via certified mail or with delivery confirmation
• Create a dedicated file for all medical bills, insurance statements, and correspondence
• Request everything in writing

Writing Effective Appeal Letters

An effective appeal letter should:

• Include your name, insurance ID, claim number, and date of service
• Clearly state that you're appealing a denied claim
• Explain why you believe the service should be covered
• Reference specific insurance policy language that supports your case
• Be concise and factual rather than emotional

Understanding Your Rights

Under the Affordable Care Act and other laws, you have the right to:

• A clear explanation of why your claim was denied
• Information about how to appeal the decision
• An external review if your internal appeals are unsuccessful
• Continued coverage during the appeals process in some cases

The Bottom Line

With denial reversal rates of 40-70% for appealed claims, having knowledgeable support through the process can make a significant difference.

The most important thing to remember is that a denial is not the final answer. With persistence, proper documentation, and possibly the help of a patient advocate, you can fight for the coverage you're entitled to receive.

Pinnie Advocates are here to help you with this Medicare covered benefit!