If you're having a health insurance dispute in Wisconsin, here's how to get help

If navigating your health insurance benefits feels like finding your way through a maze, you're not alone.

"The average person is not trained to navigate the complexities of our health care system," said Adam VanSpankeren, manager of Covering Wisconsin's Navigator Program.

Covering Wisconsin connects people with health insurance experts who can help them navigate their plan. VanSpankeren said the program often helps patients "who didn't know what they didn't know."

"It shouldn't be hard to get the right care," he said.

From figuring out what to do after your health insurer denies coverage to choosing the right insurance plan, here's what experts told the Public Investigator team about finding help in Wisconsin.

Get advice about coverage disputes and more from a local health insurance expert

Covering Wisconsin, a program of the University of Wisconsin-Madison Division of Extension, helps people sign up for and understand their health insurance.

The program's GetCovered Connector Tool can connect you with a local health insurance expert via Zoom, phone, or in person. The experts can provide advice on applications, appeals, coverage issues and more.

After entering your information and preferences, the tool will provide a list of names, phone numbers and locations of nearby organizations that can help. From there, you can schedule a free appointment with an expert of your choice.

Covering Wisconsin partners with the state's Office of the Commissioner of Insurance, which owns WisCovered.com, a hub for Wisconsin health insurance resources. At WisCovered, you can chat live with a health insurance navigator to help get your questions answered.

Something as minor as a slight miscommunication can impact a person's coverage, VanSpankeren said, which is one reason why it's important to ask for help.

"So often when it comes to people's coverage, we'll see something that, if we had been involved sooner, we could have addressed it," he said.

Getting health coverage doesn't end after your insurance company's first denial

Kasey Minnis, spokesperson for the Multiple Sclerosis Foundation, an advocacy group that helps people with MS navigate the health care system, said more people should be aware of their right to appeal after their insurance company denies their treatment or medication.

"They don't know that there is a process where they can ask their doctor's office to follow up and advocate on their behalf, or where they can actually appeal themselves," said Minnis.

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For example, if a company denies coverage because the medication isn't on its "formulary," or the list of which prescription drugs it covers, Minnis said patients can ask their doctors to submit a formulary exception.

Healthcare.gov explains how to file an appeal with insurance and ways to expedite the process. For more help, Healthcare.gov also has a tool that can help you find local help with the appeal process.

According to the state's Office of the Commissioner of Insurance, users can also submit a grievance to their insurance company and participate in the company's grievance committee meeting. The committee reviews the grievance and decides whether to resolve it in your favor or uphold the company's position.

You can also choose not to go to the meeting, according to the state Department of Health Services, but if you go, you'll be able to explain your concern in person and answer questions.

Either way, the committee has up to 30 days after getting your grievance to resolve it, the DHS explains.

How Wisconsin residents can file a complaint against their health insurance company

If you've contacted your plan or vendor and your health insurance still isn't helping you get the care you need, you can file a complaint.

The Wisconsin Department of Health Services site lists how to file a complaint depending on your plan, whether you're self-insured, employer-insured, work for the state or are part of a Medicaid, BadgerCare Plus or Medicare plan.

For example, if you work for the state or local government or are a beneficiary, one way you can submit a complaint is by contacting an ombudsperson at the Department of Employee Trust Funds.

Additionally, Medicare users can file a complaint online through the site's Medicare Complaint Form.

Meanwhile, people with individual health insurance can file complaints with the state's Office of the Commissioner of Insurance.

Sarah Smith, a spokesperson for the Office of the Commissioner of Insurance, said the nuances of navigating which entity can help can be complicated.

"They can always contact us at OCI, and we can find out whether we are the right the right ones to help, or find the right people to help," she added.

She said the agency receives many health insurance complaints related to claim denials.

"We would always encourage people to reach out to us if they feel that a claim has been denied inappropriately to what is by the terms of their policy," Smith said.

How to have an outside expert review your health insurance denial

According to the Office of the Commissioner of Insurance, health insurance users who are not covered through any federal plan or their employer's self-funded plan have the right to an independent review process.

The company's final written denial of your complaint should include a notice that explains how to request an independent review.

The free process allows a medical expert with no connection to the plan to review your appeal, who then makes a binding decision either in the patient's or the company's favor.

The expert may reverse the denial based on medical or scientific evidence, the insurance contract and any legal bases. However, the Office of the Commissioner of Insurance says you can't request an independent review if the requested treatment isn't a benefit that's listed in your policy.

An independent review process fact sheet created by the Office of the Commissioner of Insurance that details who qualifies for an independent review, what to provide to the expert conducting the review and a timeline of the typical process can be found here.

Quinn Clark is a Public Investigator reporter. She can be emailed at QClark@gannett.com. Follow her on X at @Quinn_A_Clark.

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