Your Health Insurance Is Giving You Trouble? Here’s How to Fight Back.

Most consumers experience problems with their health insurance, according to a survey released Thursday by KFF, a health-research nonprofit. Survey respondents complained that their health plans refused to pay for care that they thought would be covered, didn’t include key doctors and hospitals in their networks and delayed or denied patients’ access to treatment and drugs, among other issues.

John Ridlehoover, a retired government contractor with Medicare coverage who participated in the survey, said he sometimes struggled to get treatment he needed. Recently, when his endocrinologist ordered a continuous glucose monitor, his plan rejected it.

“Why did they turn it down? I have no idea," he said. Mr. Ridlehoover, 84, of Upper Chichester, Pa., said his doctor appealed the decision and got it reversed. The device is now helping him keep his blood sugar under control, he said.

Overall, 58% of insured adults in the survey said they had run into problems using their health insurance in the past 12 months. The share was higher for respondents who weren’t in good health. Among consumers who reported “fair" or “poor" mental health, about four in 10 reported that they hadn’t been able to get a medication or service they needed.

The survey, conducted among 3,605 people earlier this year, included those with private insurance as well as government-sponsored Medicare and Medicaid coverage.

“Right at the moment you are least able to manage administrative red tape, that’s when it hits you," said Ted Doolittle, Connecticut’s healthcare advocate. “You’re at literally your most vulnerable."

An insurance-industry trade group, AHIP, said many surveys show that consumers rate their health insurance highly. Indeed, the KFF poll showed 81% gave their insurance plan a positive rating, despite the snags that most respondents reported. An AHIP spokesman said insurers are working to improve access, affordability and convenience.

The KFF survey found that only about half of people with insurance problems were able to get them resolved to their satisfaction.

Most consumers didn’t realize they had the right to appeal health-insurance denials to an independent third party. Only about a quarter knew which government agency to contact for health-insurance problems. Many also didn’t understand the details of their own health plans.

“Overwhelmingly, people would like a 1-800-fix-my-insurance-problem place to call," said Karen Pollitz, a senior fellow at KFF. “Lots of times, people don’t know what’s going on."

Patients can take a number of steps to protect and defend themselves when they face an insurance challenge, consumer advocates and insurance experts say.

First, consumers should know their insurance plan, experts say. The federal government offers a helpful glossary of health-insurance terms here. You should also get the documents that explain the rules and limits of your plan, such as the summary of benefits and coverage. The summary should have a link to the more in-depth plan description that includes the complete terms of the plan. You can typically get documents through your insurer or employer.

These documents matter because plans can vary a lot—many, for instance, don’t cover drugs used for weight loss, like Ozempic and its sister medication Wegovy, while others do. The rules for what you have to pay out of your pocket for care are often complicated.

The KFF survey found that many of consumers’ insurance problems involved a health plan not paying for care they expected to be covered, not covering a medication or denying or delaying approval for a planned medical service. When this happens, advocates say, you shouldn’t give up.

“Don’t take no for an answer," said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, which offers consumer-health advocacy services. “Fight, fight, fight."

Consumers can start by calling the health insurer and asking about why a treatment was rejected or a bill wasn’t covered, as well as the procedures for filing an appeal. The appeal option should also be flagged on documents you get from the insurer, such as the “explanation of benefits."

Advocates say consumers should always take detailed notes about their conversations with insurers, including the times and dates of calls and the names of company representatives, as well as saving all their paperwork. Paperwork will include important information like the billing codes for the services that you are seeking coverage for.

Also: Don’t wait too long, since insurers may have deadlines for appeal eligibility.

For help crafting an appeal, consumers can turn to state assistance programs—you can find out if your state has one here. For Medicare, there are also special programs available in each state, here. Some programs offer do-it-yourself instructions, like these.

There are also nonprofits that can help with insurance appeals, such as the Patient Advocate Foundation, the Center for Medicare Advocacy and the Medicare Rights Center. Low-income consumers and Medicaid beneficiaries may be able to get free legal help; look here. Patients may also want to hire an advocate, and these online directories can help connect you with someone.

The first appeal is typically internal, with the insurer. You should work closely with your doctor or hospital, which may be able to file the appeal on your behalf. Sometimes the problem is just that a piece of required information wasn’t included in initial claims or requests for authorization they filed.

For more-complex situations, Benjamin suggests consumers do a written appeal, rather than simply a phone request, so they can marshal more-detailed evidence and retain a record of when the appeal was filed, via email or fax.

If the issue is that the health plan deemed the carenot medically necessary, your doctor can write a letter explaining why the care you want is needed, citing medical literature. You might want to gather your own research as well—you can look up studies here.

You should also review your plan’s medical policies to see if the rejection was in line with the insurer’s own rules. These are often available publicly—for instance, here are some links for CVS Health’s Aetna, Cigna Group, and UnitedHealth Group’s UnitedHealthcare.

If the insurer reaffirms its rejection, it’s still not the end of the line. You generally have the option to appeal to a third party, often an independent review organization or a government-administered process. Information on how to do so should be offered to you, typically in the rejection letter you get from the insurer.

If you can’t find it, your state insurance department should be able to help, and you can find its contact information here. For Medicare, here are instructions that include how and when to go to a third-party review, and here are federal guidelines.