Former Insurance Worker Reveals The Secret Way You Can Actually Fight Health Insurers When They Deny Claims
There's a way to beat them at their own game. Most people just don't know it exists.
Minerva Studio | Canva Pro Well! We're having quite the national reckoning about the American healthcare system at the moment, aren't we?
Moral questions aside, it's not at all surprising that the case of Luigi Mangione, accused of murdering UnitedHealthcare CEO Brian Thompson on December 4, has sparked so much discourse.
Most of us, at one time or another, have dealt with the cruel and capricious whims of American health insurance companies — and have felt powerless because of it. But it turns out there's a readily available way to fight them, most people just don't know about it.
A former insurance employee shared how to fight health insurer claim denials with a 'fair hearing trial.'
It hopefully goes without saying that violence is not the best way to deal with health insurance disputes, as understandable as the instinct might be. As TikToker Junk Mother, aka @junkmotherjess, irreverently put it in a video on the subject, "We can't 'pew-pew' every CEO; they're just gonna find more."
Because of how secretive health insurers are and how variable their practices tend to be from company to company, exact statistics on denials are hard to come by. However, an analysis by health policy research organization KFF found that nearly 1 in 5 claims are denied, with some insurers rejecting as much as 49% of claims.
It's shockingly and egregiously common, and as has been pointed out again and again recently, it often results in patients living in abject pain or, worse, dying because of inadequate medical care they pay through the nose for. But as Jess explained, there is a way to fight back — demanding what's called a "fair hearing trial."
A 'fair hearing trial' puts your claim denial before state regulators and often a judge.
Jess explained that fighting claim denials is often shockingly easy — though this varies heavily from state to state. Many states require fair hearing trials to be a last resort after all other internal options with your insurer have been exhausted, so do be aware that the process can be lengthy.
However, Jess called the phrase itself "magic words" for many insurers, and explained how to go about leveraging them. "They call you, they tell you your claim has been denied. You say, thank you so much; I'm going to file a fair hearing trial," Jess said.
"As soon as you say those magic three words," she went on to say, "the insurance company is gonna offer you an appeal, to which you are gonna say, no, thank you, joker."
Instead, she said to google "fair hearing trial" plus your state to initiate the process. Again, you may be required by state law to exhaust all other options with your insurer first. But what ultimately happens in the fair hearing process is that your claim denial is put before regulators or a judge.
And that means you automatically have the upper hand because, as Jess explained it, "what's gonna happen is, the insurance company is gonna have to bring their case to the state to prove why you don't need the service." And who is the state going to ask to prove that? Your doctor, not some paper-pusher at an insurance company who's not qualified to make the determination in the first place.
Often, the threat of a fair hearing trial is enough to make a health insurer relent.
These hearings typically go in the patient's favor, though some states are more favorable to patients than others. But many times, the fair hearing itself never even happens because just the invocation of the phrase "fair hearing trial" alone is often enough to make an insurer back down.
As physical therapist and content creator Dr. Dan Ginader put it, "Insurers hate these, and even the threat of one can bring them down on their knees and in your favor." Having to prove their case to a judge is often far more difficult and costly than simply approving your claim, after all.
Dr. Ginader also noted that there are other options besides fair hearings when your claim is denied that you can try first, including having your doctor argue with your insurer on your behalf in what's called a "peer-to-peer review," hiring an insurance lawyer and even using AI tools that can do the fighting for you.
The bottom line? "Let's not all become fugitives," Jess pithily said in her video. Instead, leverage these methods and put your insurer on their back foot. Their unjust and barbaric rules are all made up anyway.
John Sundholm is a writer, editor, and video personality with 20 years of experience in media and entertainment. He covers culture, mental health, and human interest topics.