健康保险拒赔时该怎么办

ABC电视台在吉米·坎摩尔就右翼对查理·柯克遇刺事件的反应发表玩笑言论，以及联邦通信委员会主席发出威胁后，暂停了他的节目。本周《Consider This》节目将探讨这一事件对言论自由及电视网商业运作的启示。请通过NPR应用或您获取播客的任何平台收听《Consider This》。

ABC suspended Jimmy Kimmel after a joke about the response from the right to the assassination of Charlie Kirk and after a threat from the FCC chair. This week on Consider This, what it says about free speech and about the business of network television. Listen to Consider This on the NPR app or wherever you get your podcasts.

您正在收听NPR出品的《生活指南》。大家好，我是玛丽埃尔。我一生中收到过无数意料之外的医疗账单，多到一只手都数不过来。这些账单上的服务项目本应由我的保险承担。而每次，我的情绪反应都是愤怒。

You're listening to Life Kit from NPR. Hey, it's Marielle. I have gotten a number of surprise medical bills in my life, more than I can count on one hand. Bills for services that I expected my insurance to cover. And every time, my emotional response has been rage.

愤怒。因为现在我不得不处理额外事务。愤怒。因为我得翻出医保卡，打电话联系相关人员，在等待他们调查时听着无尽的等待音。愤怒因为账单上写着'收到即付'，仿佛倒计时已经开始。

Rage. Because now I have homework to do. Rage. Because now I have to dig up my insurance card and call people on the phone and wait on hold while they look into the matter. Rage because the bill says due upon receipt and it feels like the clock is ticking.

愤怒因为我本对午休时间另有安排。愤怒因为我们的医疗体系为何如此不堪？我说这些是想表达：如果你在处理医疗账单和保险流程时感到愤怒、沮丧或精疲力竭，这些情绪完全合理。当你准备好时，我们有些建议给你——特别是关于当收到本应作为预防性护理被保险覆盖的医疗账单时该如何应对。

Rage because I had other plans for my lunch break. Rage because why is our healthcare system like this? I say all this because I want to acknowledge if you feel rage or frustration or exhaustion or any of the above when you're dealing with medical billing and insurance bureaucracy, that is understandable. And when you're ready, we have advice for you. Specifically, we have advice on what to do when you get a medical bill for something that should have been covered by your insurance as preventative care.

记者杰基·福蒂尔一直为KFF健康新闻与NPR合作的《医疗求助热线》项目追踪报道此话题。在本期《生活指南》中，她将详细指导我们该联系谁、如何沟通，以及申诉此类医保拒赔所需准备的材料。

Reporter Jackie Fortier has been covering this topic for a KFF health news and NPR project called Healthcare Helpline. And on this episode of Life Kit, she's gonna talk us through some tips so you'll know who to call, what to say, and what information you need to appeal a health insurance denial like this.

接下来请收听NPR《贯穿线》节目。

On the next through line from NPR.

人们对此确实存在伦理和道德困境。从一开始就感到不适。

People have real ethical and moral quandaries about this. People are uncomfortable from the very beginning.

移民拘留的生意。

The business of migrant detention.

在NPR应用或任何你获取播客的地方收听。

Listen in the NPR app or wherever you get your podcasts.

嗨，我是Rachel Martin，NPR《Wildcard》节目的主持人。在我多年担任电台主持人的生涯中，沉默曾让我感到紧张。那种等待回答前的停顿，因为你不知道麦克风另一端发生了什么。

Hey. It's Rachel Martin. I'm the host of Wildcard from NPR. For a lot of my years as a radio host, silence sort of made me nervous. That pause before an answer because you don't know what's going on on the other side of the mic.

但现在，我爱上了这种沉默。

But these days, I love it.

天哪。

Gosh.

哇哦，给我一分钟。

Woah. Give me a minute.

对，对，思考一下。

Yeah. Yeah. Think.

请收听NPR独家播出的《野卡牌》播客。

Listen to the wildcard podcast only from NPR.

国会结束夏季休会重返工作，议程上事务繁多。立法者们将面临哪些议题？他们的工作对您意味着什么？NPR政治播客每周工作日为您解析华盛顿内部运作。通过NPR应用或任意播客平台收听NPR政治播客。

Congress is back from its summer recess with a lot on its agenda. What's all in store for lawmakers, and what does their work mean for you? Every weekday, the NPR Politics Podcast unpacks Washington's inner workings. Listen to the NPR politics podcast on the NPR app or wherever you get your podcasts.

我以为预防性医疗应该是免费的。

So I thought preventative care was supposed to be free.

是的。根据《平价医疗法案》，在多数情况下推荐的预防性医疗服务本应无需自付费用。但拒赔仍会发生，有时是由于账单问题、编码错误，或是医生就诊的分类方式导致的。

Yeah. Under most circumstances, recommended preventive care is supposed to be covered at no out of pocket cost under the Affordable Care Act. But rejections do still happen, and sometimes because of billing issues or coding mistakes or how a visit, you know, with the doctor is classified.

那我们从基础问题开始——联邦法律规定的预防性医疗包括哪些？

Well, let's start with the basics. What's considered preventative under federal law?

这份清单其实相当长，但主要包括：年度体检、流感疫苗/带状疱疹疫苗等接种、乳腺癌筛查/结肠镜检查等癌症筛查，以及包含乳房和盆腔检查的女性健康检查。这些都是联邦卫生机构推荐的项目，法律规定多数医保计划必须全额覆盖这些项目。

Yeah. It's actually a pretty long list, but here are some of the the big ones. Annual physicals, vaccines like flu, shingles, cancer screenings like mammograms, colonoscopies, and then well woman visits, which include breast and pelvic exams. These are all recommended by federal health agencies, and most health plans have to cover them by law. No out of pocket costs.

针对不同人群有专门的预防性医疗服务清单，比如女性、儿童、青少年群体，以及癌症或妊娠等特定病症的预防护理，您可以查阅相关清单。

There are specific lists of preventive care for groups of people. So you can go check those out for women, children, and teenagers, and for specific conditions like cancer or pregnancy.

是的。从某些方面看，这份清单似乎相当直接明了，但你的资格也会因年龄、性别和健康史而异，对吧？比如当我们讨论像乳腺X光检查或结肠镜检查这样的癌症筛查时，它可能被视为预防性检查并涵盖在你的保险范围内，也可能不会。

Yeah. And in some ways that seems like a pretty straightforward list, but also your eligibility will vary based on your age and gender and health history. Right? So when we talk about cancer screenings like mammograms, for instance, or colonoscopies, it might be considered preventative and covered for you or it might not.

没错。根据你的年龄和健康史，最好在就诊前尽可能查看具体的预防性护理覆盖清单。

Yeah. Depending on your age and your health history. It is best to look over the specific list of preventative care that's covered before you go in if you can.

什么情况下年度健康访问会变成需要付费的问题就诊或诊断性就诊？

What can turn an annual wellness visit into, you know, a a problem visit or a diagnostic visit that requires payment?

是的。遗憾的是，并非所有在健康访问或年度体检中提供的护理都符合联邦指南下的免费预防性护理标准，这确实很烦人。所以情况可能很复杂，且存在解释空间。如果在体检过程中出现健康问题，比如引发讨论的异常痣或心悸，这部分咨询可能会被单独计费。因此患者可能需要为此支付共付额或扣除额。

Yeah. So, unfortunately, not all care that may be provided during a wellness visit or an annual physical counts as no cost preventive care under federal guidelines, which is really annoying. So it can be complicated and kind of open to interpretation. If a health issue comes up, like during a checkup that prompts a discussion, you know, you're talking to your doctor, like an unusual mole or heart palpitations, that consult can be billed separately. So the patient could then owe like a co payment or a deductible charge for that part of the visit.

在这种情况下，你可以询问医生他们将如何编码这次就诊，是否仍被视为健康访问的一部分。有些医生会将其视为健康访问的一部分，而其他医生可能会对相关讨论额外收费。

So in that scenario, you could ask the doctor, you know, how they're gonna code this if this is still considered part of your, wellness visit. Some doctors, you know, would consider it part of the wellness visit and other ones might add on an additional charge for chatting about that.

好的。举个常见例子：假设我40岁，符合常规乳腺X光检查资格。我去做了检查，却收到了账单。这是否意味着账单可能有误？

Okay. Let's take a common scenario. Like, say, I'm 40 and I'm eligible for routine mammograms. I go and do one, but then I get a bill for it. Does that mean that bill might be wrong?

没错。如果符合预防指南且由网络内医疗机构执行，应100%全额报销。你可能会意外收到账单——可能是医疗机构未向保险公司提交索赔，或保险公司拒付。但像你描述的这种拒付情况，通常可以通过申诉成功撤销。

Yeah. If it meets the preventive guidelines and it was done by an in network provider, it should be covered 100% no cost to you. You can be billed by accident. You know, the provider may not have submitted the claim to insurance or you get a rejection from insurance. But a rejection in that case that you outlined is often something that you can appeal and win.

是啊。这种意外账单我遇到太多次了，数都数不清。特别烦人，因为你收到账单上大写标着‘收到即付’。对吧？然后你上保险公司网站一查，发现他们压根没提交过理赔申请。

Yeah. The billing by accident has happened to me too many times to count. It's so annoying because you get this bill and it says, due upon receipt in all caps. Right? And then you look on your insurance company website and you can see a claim was never submitted.

接着你打电话给医疗账单部门质问怎么回事，为什么没提交理赔？结果要么是他们提交错了保险公司，然后放弃治疗直接找我收费，要么就是压根没提交。他们还轻描淡写说‘哦，系统出错自动发送了’。

And then you call the medical billing office and you say, like, what's the deal? Why didn't you submit this claim? And either they submitted it to the wrong insurance company and then gave up and just billed me, or they just didn't submit it. And they're like, oh, that was an error. Our system just sent that out.

说让我别理会。但在此期间我可能已经付了这笔冤枉钱，而且他们大概率不会主动告知我。

Disregard. But I could have, in the meantime, paid that bill, and they wouldn't have told me probably.

没错。就像你描述的，必须像保姆一样盯着他们确保流程正确，这确实很烦人。但如果不这么做，最终可能要承担本不该支付的巨额费用。

Yeah. And, I mean, like you're describing, it's really annoying to have to babysit them and make sure that it's done correctly, but it can end up costing you a lot of money that you shouldn't have to pay.

明白了。那如果发现他们提交了理赔申请，但我的医保不报销，或者只报销部分，接下来该怎么办？

Okay. And if you do see that they submitted the claim, but my health insurance isn't covering it, or they're only covering part of it, what do you do from there?

首先别慌。看起来吓人，但保险公司就指望人们放弃。实际上很多申诉案例是能成功的。

Yeah. So first things first, don't panic. It looks scary. Insurance companies really count on people giving up. But in many cases, appeals do work.

记住个小技巧：别把第一次拒赔当作最终答复。那只是个起点，更像是‘除非你据理力争，否则我们暂时拒绝’。所以一定要积极申诉。不过话说回来，这确实不容易。

So a tip to remember is not to take the first no as the final answer. It's really just a starting point. It's more like, you know, we said no for now unless you speak up. So make sure to speak up. And that being said, it is hard.

这很耗时。我和安娜·多伊彻聊过，她的小儿子需要每隔几个月做一次听力检查，但她的保险不涵盖这部分费用，她不得不利用午餐时间打电话与保险公司周旋。

It is time consuming. I talked to Anna Deutcher whose baby son needs hearing tests every few months that her insurance wouldn't cover, and she would spend her lunch breaks on the phone with the insurance company.

感觉负担全落在了只想获得医疗保健的人身上，但我本不该同时操心医院是否正确编码、保险公司是否合理赔付。我应该关注他的健康，而不是替别人操心他们本该做好的本职工作。

It feels like the burden goes on the person who's just trying to get health care, but I don't need to also make sure that the hospital codes it correctly and the insurance company covers it properly. And I should be worried about him, not about what other people's jobs should be to do properly.

这太让人沮丧了。

It's so upsetting.

是啊。她花了数月时间争取让1200美元的预防性听力检查获得赔付，因为自费支付确实让她的家庭经济吃紧。所以，如果你和安娜有同样遭遇，我们随时可以讨论维权步骤——你并不孤单，这也不是你的错。

Yeah. I mean, she fought for months to get $1,200 of preventive hearing tests covered because it really strapped her family financially to pay out of pocket. So, you know, if you feel like Anna, we are here to talk about the steps to take to fight it because you are not alone and you haven't done anything wrong.

嗯。这是个很好的提醒。那么，现在我看着保险公司来信或门户网站，他们说这项预防服务不在承保范围或只部分承保。

Yeah. That's a really good reminder. So okay. I'm looking at the letter or the insurance company portal. They say this preventative service wasn't covered or was only partially covered.

我该怎么办？

What do I do?

仔细阅读那份拒付文件。保险公司必须告知拒赔理由。每位被拒绝赔付的参保者都有权申诉。接下来我们要讨论预防性护理被拒时的应对策略——通常你会收到一份保险利益说明书。

So read that rejection document carefully. The insurance company has to tell you why they aren't covering the claim. And everyone who's who has had care denied has the right to appeal. So we're going to talk about, what that means when it's preventive care. You usually get an explanation of benefits.

这不是账单，而是列出了你的医疗费用明细、保险公司支付金额以及你需要自付的部分。上面可能会标注‘非医疗必需’或‘不在承保范围内’等字样。这些都是保险术语，但重要的是要弄清楚他们拒绝赔付的原因。如果表述不清，就打电话询问——你的保险卡背面就有客服电话。

That is not a bill, but it lists the cost of your care and how much the insurance company will pay and then what you owe. So it might say something like not medically necessary or not a covered benefit. It is insurance speak, but it's important to figure out why they told you no. And then if it's not clear, call them. There's a customer service number on the back of your card.

保持礼貌，多提问。记录下所有沟通细节：对话人姓名及其答复内容。如果能拿到书面说明就更好了。

Be polite. Ask questions. Write down everything, who you talked to and what they said. And if you can get it in writing, that's even better.

所以关键是要获取具体拒赔理由，而不仅仅是被告知被拒。

So it sounds like get the reason, not just the rejection.

没错。你必须知道拒赔原因才能据理力争。之后你可以对拒赔决定提出申诉——这被称为内部申诉，因为是在保险公司内部流程中进行。

Yeah. Exactly. You need to know why they said no in order to fight it. And then you can appeal the denial. And this is called an internal appeal because it's within the company.

你不需要具备法律专业知识。你只是要求保险公司重新评估其决定，争取让他们支付部分医疗费用。查阅你的保险条款（通常称为计划概要说明书），里面会载明承保范围、免责条款以及申诉所需满足的条件。

You don't need to be a lawyer to do it. You're just asking the insurer to reconsider their decision, not to pay for a certain portion of your care. So pull up your insurance policy. It's usually called the summary plan description. It'll tell you what's covered, what's not, and then what hoops you have to jump through to appeal it.

明白了。那么在此期间，我正在和保险公司交涉，但可能已经收到医院或医疗账单办公室的账单。我该怎么处理？能打电话告诉他们‘我正在和保险公司协商，暂不支付，因为我认为这笔费用本应被报销’吗？

Okay. In the meantime, right, I'm dealing with the insurance company, but maybe I've also gotten a bill from the medical billing office or the hospital. What do I do with that? Like, can I call them and say, I'm still working this out with my insurance, so I'm not gonna pay y'all yet because I think this should have been covered?

当然可以。你完全应该联系账单部门说明情况。如果你正处于申诉流程中，他们不能向你催收款项。但必须及时启动申诉程序——虽然可能有长达六个月的期限，但最好立即着手准备申诉所需的文件材料，这需要时间。

Yes. You absolutely should call the billing department and tell them the situation. If you're in the appeals process, they can't collect from you. But you need to get that clock going. You may have up to six months, but, you know, it's best to get the ball rolling and start collecting the documents that you'll need for an appeal, which takes time.

务必查看拒付信上的确切截止日期。最佳做法是不要忽视它。别把账单转到信用卡上，那样会变成信用卡债务，你将失去医疗债务享有的诸多保护措施。所以联系账单部门，告知他们你正在申诉。

And be sure to check the denial letter for your exact deadlines. So the best thing to do is don't ignore it. Don't put the bill on a credit card because then it changes it into credit card debt, and you lose a bunch of protections that you have with medical debt. So contact the billing office and tell them that you're appealing it.

好的。能详细说明具体操作步骤吗？

Okay. And can you walk me through the steps to do this?

当然可以。通常保险公司官网会有申诉表格需要填写。如果网上找不到，可以查看你的保险福利说明文件。

Yeah. Totally. So a lot of the time, there's an appeal form that you'll need to fill out. It's likely on your insurer's website. If you can't find it online, look at your explanation of benefits.

好的。

Okay.

那需要准备哪些类型的文件呢？

And and what kinds of documents would I need to gather?

这点非常重要。申诉需附上医疗证明：写说明信解释异议原因，附带相关病历或检测报告。如果是预防性服务，还需提供注明该条款的联邦法规副本。

Yeah. So this is really important. Back the appeal up with medical evidence. You wanna write a letter explaining why you disagree with the rejection, then include any relevant medical records or test results. And if it's a service that's supposed to be preventive, include a copy of the federal regulations that say so.

尽可能让医生出具证明信，内容类似'该治疗对患者具有医疗必要性和预防性'。医生的专业意见在申诉过程中很有分量。比如保险公司拒付本该涵盖的心理健康筛查时，这类支持材料就特别关键。

And if you can, get a letter from your doctor. This can be a big help. Something along the lines of this treatment is medically necessary and preventive for this patient, you know, because then their medical reasoning from the doctor. That kind of support really does carry weight within the appeals process. So let's say your insurance denied coverage for a mental health screening, which is something that should be covered.

你的申诉信可以这样写：我对4月1日心理健康筛查相关的理赔拒赔提出申诉。保险公司声称这不属于预防性服务，但在这份支持文件中，它被列为预防性服务。随信附上我的医生史密斯博士的信函，他解释了为何这在医学上是必要的。所以，把它想象成在法庭上陈述案情。申诉无关情绪。

Your appeal letter might say, I'm appealing the claim rejection related to mental health screening on April 1. The insurance company stated it was not preventive, but in this supporting document, it's listed as a preventive service. Enclosed is a letter from my doctor, doctor Smith, who explains why it's medically necessary. So think of it like making a case in court. Appeals are not about emotion.

它们关乎文件证明。

They're about documentation.

好的。所以我不要在信里提及这件事如何影响我的财务状况，或者我对他们处理不当有多愤怒？

Okay. So I shouldn't include in the letter how this has affected me financially or how mad I am about their mishandling of this?

是的。遗憾的是，这对你的案件没有帮助。虽然宣泄情绪可能让你感觉好些，但你得让申诉信简洁、得体且基于事实。

Yeah. Unfortunately, that won't help your case. It might feel cathartic, but, you wanna make it, you know, short, sweet, and factual.

明白了。那么你收集好那些文件，写好申诉信，然后直接提交看看结果如何？

Alright. So you you gather those documents, you write your letter, then you just hit submit and see what happens?

不完全是这样。你需要确保他们确实收到了申诉。可以通过他们的在线门户上传——通常他们会有这样的系统，或者用挂号信邮寄。有些人觉得后者更稳妥。

Not quite. You wanna make sure that they actually receive it. So either upload it to that portal. They usually have one online, or you can send it via certified mail. Some people feel more comfortable that way.

这样你就有投递证明了。当然，还要保留所有材料的副本作为自己的记录。务必留意信用报告，确保那笔账单不会显示为未付或拖欠等状态。有时候，他们可能会对你的申诉回应说：我们搞错了。

And that way you have proof that it was delivered. And then, of course, keep copies of everything, you know, for your own records. Make sure to keep an eye on your credit report and make sure that that bill isn't showing up as an unpaid or, delinquent or anything like that. And then, you know, in some cases, they might say to your appeal, you know what? We screwed up.

是我们的疏忽，我们本应为你承担这笔费用。所以务必让他们书面确认同意赔付，之后持续关注你的信用报告，并将这份书面证明保留一年左右。

Our bad. We should have covered you. So make sure that you get that in writing, that they have decided to cover you and then keep an eye on your credit report and hang on to that confirmation in writing for about a year.

好吧，这一切太烦人了。杰基，真的太糟心了。你不过是去看了医生，还得专门请假。

Okay. This is all so annoying. It's so annoying, Jackie. Like, you just went to the doctor. You had to take time off of work to go to the doctor.

要知道，你得打电话预约，听着漫长的等待音乐，去医院做宫颈抹片检查或抽血时还得忍受各种折腾。结果现在还要处理这些破事。

You know, you had to call up and sit on the phone to make the appointment and listen to the whole music. You had to go in and get prodded when you get a Pap smear or when you get your blood taken. And then on top of it, you have to do this.

事情不该是这样的。很多人都有各自的生活要应付，对吧？就像我之前提到的安娜，她儿子本应享受的听力检查被拒赔——她当时刚生产完重返职场，既要全职工作又要照顾新生儿，突然又接到孩子需要定期听力测试的诊断。

It shouldn't be this way. And I mean, lot of people people have lives. Right? So you could be, like Anna, who I was talking about earlier, who needs those hearing tests for her son that should have been covered. I mean, you know, she was getting over giving birth, going back to work, working her full time job, having a newborn, and then gets this diagnosis that he needs these intermittent hearing tests.

所有这些压力之外，她还不得不在午休时间和保险公司扯皮争取赔付，简直糟透了。

She has all of this on top of then, you know, on her lunch hours fighting with the insurance company in order to pay for it. It's awful.

稍后我们将讨论如果保险公司拒绝申诉时的应对方案。请记住你仍有选择余地——广告之后继续。

Coming up, we'll talk about your options if the insurance company denies your appeal. You do have options. That's after the break.

正值金秋时节，或许你正在挑选万圣节装扮，或是寻找哪里能买到南瓜香料拿铁。若想了解今秋热门影视推荐，请锁定NPR《流行文化欢乐时光》播客节目，在NPR应用或任意播客平台均可收听。

It's fall, so maybe you're figuring out your Halloween costume or where to get a pumpkin spice latte. And if you wanna know what buzzy movies and TV shows to check out this fall, we've got you covered. Listen to pop culture happy hour in the NPR app or wherever you get your podcasts.

好的，我们继续回到LifeKit的话题。

Okay. We're back with LifeKit.

杰基，如果

Jackie, what

保险公司拒绝了你的申诉怎么办？

if the insurance company says no to your appeal?

你仍有选择余地。有些人在第二次尝试时成功。如果他们再次拒绝，千万别放弃。好吗？所以我们下一条建议是：你可以申请外部医疗审查。

You still have options. Some people win on the second try. If they say no again, do not give up. Okay? So our next tip is you can request an external medical review.

这是由独立医疗专业人员审核你的案例，并决定你的健康保险是否应涵盖该治疗。这就像是医疗决策的最高法院。他们的裁决是最终决定，不可上诉。但这个过程公正无偏倚，基于医学依据，并且对保险公司具有法律约束力。

This is when an independent health professional takes a look at your case and they decide whether your health plan should cover it. This is like the supreme court of health decisions. Their decision is final, and you cannot appeal it. But it's unbiased, it's medically based, and it is legally binding for your insurance company.

明白了。就像中立的第三方可以说：嘿，这个人确实需要这项治疗。

Okay. So it's like a neutral third party that could say, hey. This person actually does need that care.

没错。最棒的是你无需独自应对。许多州都有免费协助你完成这个流程的工作人员。当然，这取决于你所在的州份。有时是州保险部门或总检察长办公室提供帮助。

Yeah. And the best part is you don't have to figure it out alone. A lot of states have people that will help you through this process for free. Of course, it depends on the state you live in. Sometimes it's your state department of insurance or the attorney general's office.

此外还有许多非营利性消费者援助项目。不过通常来说，这些机构已经习惯了人们不知道该找哪家的情况。所以你可以打电话给比如总检察长办公室，说‘嗨，我遇到了这个问题’，他们就会指引你去哪里寻求帮助。

There's also a lot of nonprofit consumer assistance programs. But usually, I mean, they're used to people not knowing which one to go to. So you can call, like, the AG's office and say, hey. I have this problem, and they'll direct you as to where you can go to get help.

明白了。如果想申请外部医疗审查，是从这里开始吗？具体要怎么申请呢？

Okay. Is that where you start if you want an external medical review? Like, how do you actually request that?

保险公司必须在发给你的文件中说明具体流程。法律要求他们必须告知你有权申请外部医疗审查，并列出需要遵循的步骤。但这些信息通常埋藏在难以理解的法律术语中。所以我强烈建议人们去寻求帮助——通常是州级机构的工作人员。令人惊讶的是，很多机构的官网上都有非常详尽的信息。

The insurance company has to tell you how to do it in the documents that they send you. They're required by law to tell you that you, have the option to do an external medical review and the steps that you have to follow. But it's usually really buried and in this kind of legalese that can be hard to read. So I would definitely recommend that people go and get help from, folks, usually at the state level. A lot of them have really good information on their websites, surprisingly.

这种外部医疗审查的成功率有多高？

How often does this work, the external medical review?

相当频繁，结果很出人意料。我曾与加州医疗保健管理部主任玛丽·渡边交谈，她说了一个让我非常惊讶的数据。

Pretty often. It's surprising. I talked with Mary Watanabe, who's the head of the California Department of Managed Health Care, and she said something that really surprised me.

72%向本部门提交独立医疗审查的医保计划成员，最终都获得了他们申请的服务。

Seventy two percent of health plan members that come to us and file an independent medical review end up getting the service that they requested.

这个概率很不错。

Those are good odds.

是的。我是说，七成人的服务费用能得到报销。这已经相当不错了。

Yeah. I mean, seven in ten people get the service paid for. I mean, that's that's pretty great.

你需要自行寻找第三方进行这项审核吗？还是由保险公司或州监管机构提供这项服务？

Do you have to find the third party who does this review? Or is that provided by either the insurance company or your state regulatory agency?

不，由保险公司提供。外部医疗审核的健康专业人员可能来自他们需要签约并付费的第三方机构。但根据联邦健康法规定，他们必须配备外部医疗审核人员。有时可能会收取少量费用。

No. It's provided by the insurance company. The external medical reviewer, the health professional, can be part of like a third party that they have to contract and pay for. But under federal health law, they have to have an external medical review person. Sometimes there might be a little bit of a fee associated with it.

不过费用是象征性的，大概20美元左右。

Like, it's nominal, though. It's, like, $20.

外部医疗审核通常需要多长时间？

How long does the external medical review usually take?

标准审核最长可能需要45天。但如果情况紧急，比如你的健康面临严重风险，可以申请加急审核，结果会在7天或更短时间内出来。

So the standard review can take up to forty five days. But if it's urgent, like your health is at serious risk, you can request an expedited review. And that gets decided in seven days or less.

如果医疗审核员不支持你，导致这项服务未获批准怎么办？

What if the medical reviewer does not side with you and you don't get this service approved?

是的。很多人到了这一步可能会感到绝望。你已经做了这么多努力，提交了多次申诉。现在这位独立医生却说，不行。

Yeah. So this is kind of the point where a lot of people may feel hopeless. You've done all this work. You've filed, you know, multiple appeals. Now this independent doctor says, nope.

这不属于预防性医疗。保险公司不必为此买单。我询问了全国消费者法律中心的高级律师伯妮塔·海恩斯，人们该怎么办？

This isn't preventive care. Insurance doesn't have to cover it. I asked Bernita Haynes, senior attorney at the National Consumer Law Center, what should people do?

你仍有几种选择：要么与医疗服务提供方协商账单，要么根据你所在州的规定，若当时未投保或保险不足，可能仍有时间申请医疗费用财政援助。

You still have some options to either negotiate the bill with a provider, or if you were uninsured at the time or underinsured at the time, depending on your state, you still may have time to apply for financial assistance for the bill.

所有非营利医院（很多医院都是非营利的）都必须提供财政援助，因此你可以申请。如果不符合条件，还有另一个建议：联系医生办公室或医院财务部门要求降低账单。听起来有点离谱，但确实可行。海恩斯说他们只想要收到钱，如果你支付现金，有时会有折扣。

So all nonprofit hospitals, and a lot of hospitals are nonprofit, have to offer financial assistance, so you can apply for that. If you don't qualify, here's another tip. You can contact the doctor's office or the hospital billing department and ask them to lower the bill. It sounds kind of outlandish, but you can do that. Haines said they just wanna get paid, you know, if you offer cash, sometimes there's a discount.

如果他们同意减免，务必以书面形式确认协商后的金额。如果是分期付款，确保不收取利息和滞纳金。

And then if they agree to that, make sure to get the negotiated amount in writing. If it's a payment plan, make sure there's no interest being charged and no late fees.

我们做过一期关于如何降低医疗账单的节目，其中有个建议是询问他们结算金额是多少——比如如果今天结清，你们愿意接受多少金额？

We did an episode on how to lower your medical bills, and one tip we got was to ask them what's the settlement amount? Like, how much would you take today to close this account if I gave you

感觉有点像买二手车时的讨价还价。

a It kinda feels like buying a used car.

对，对，对。你可以的，你可以做到。就像，你可能没想过要讨价还价医疗债务，但这确实是可能的。

Yeah. Yeah. Yeah. You can do you can do it. Like, you don't think to try to haggle over your medical debt, but it is possible.

还有一件事我一直好奇，你知道，我们很多人通过工作获得健康保险。当保险公司拒绝你认为应该涵盖的服务时，你的工作单位能提供任何帮助吗？

One other thing I've been wondering about, you know, a lot of us get our health insurance through work. Can your job help at all when your insurance company says no to a service that you think should be covered?

是的，他们可以。如果你通过雇主获得保险，联系你的人力资源部门，告诉他们发生了什么。你还记得我之前提到的安娜·多伊彻吗？她儿子需要听力测试。

Yeah. They can. If you have insurance through your employer, get in touch with your human resources department and let them know what's going on. Do you remember Anna Deutcher whose son needed the hearing test? I talked about her earlier.

记得。

Yeah.

她就是这么做的，而且成功了。

That's what she did, and it worked.

我也从未因为类似的事情去找过HR。

I also have never gone to my HR for something like this before.

我甚至不知道这是个选项。她告诉HR她儿子未来几年都需要这些听力测试。雇主决定报销安娜已经自费支付的测试费用。他们还表示会在下一个保险年度为所有参保人增加听力检查，但不作为预防性项目。这意味着安娜下次听力测试需要自付部分费用。

I didn't even know this was an option. She told HR her son would need these hearing tests for years. Her employer decided to pay Anna back for the tests she'd already paid out of pocket for. They also said they'd add hearing exams for everyone on their insurance in the next plan year, but not as preventive. That means Anna will have a copay for the next round of hearing tests.

这有点让人恼火，因为公司从未表示他们本应从一开始就将他的听力检查作为预防项目纳入保险范围。我们的专家解读联邦法律后认为，安娜根本不应该支付任何共付额。但总的来说，安娜很高兴她未来几年都不必全额承担他的听力检查费用。

That's a little irritating because the company never said that they should have covered his hearing tests from the start as preventive. Our experts reading of federal law was that Anna shouldn't have to pay a copay at all. But overall, Anna's happy that she won't have to pay the full cost of his hearing tests, you know, for years to come.

是啊。至少问题部分解决了，但还是挺烦人的。嗯。不过我认为这是个实用建议——如果你遇到健康保险拒赔本应涵盖的项目，无论是预防性服务还是其他，记得去找人力资源部。

Yeah. I mean, I'm glad it's at least somewhat taken care of, but that is annoying. Mhmm. I think though this is a good tip in general if you're having an issue with your health insurance denying claims that you think should be covered, whether it's a preventative service or not. Go to HR.

对吧？因为这可能是系统性错误。由于保险公司的过失，你的同事们可能也遇到过同样的问题。

Right? Because there might be a pattern. Your coworkers maybe have experienced this too because of some mistake on the insurance company's end.

没错。这能帮助HR发现潜在趋势，从而在公司层面与保险公司交涉。要知道，雇主为员工健康保险支付了巨额保费，他们理应确保员工获得已付费的保障服务。

Yeah. It could help HR folks, you know, see a trend that they might wanna address at the company level with the insurance company. I mean, keep in mind, your employer pays a lot of money for your health insurance. So they should want to get the services provided to their employees that, you know, they're paying for.

杰基，非常感谢你为我们详细解析这件事。

Jackie, thank you so much for walking us through this.

不客气。

Yeah. Thank you.

刚才接受采访的是KFF健康新闻记者杰基·福蒂尔。现在进入要点回顾：第一，根据联邦法律，健康保险计划必须全额承保特定预防性服务，包括年度体检、疫苗接种和癌症筛查等项目，参保人无需自付费用。

That was KFF Health News reporter Jackie Fortier. Alright. It's time for a recap. Takeaway one, under federal law, there's a list of preventative services that must be covered by your health insurance plan with no out of pocket costs. They include things like annual physicals, vaccines, and cancer screenings.

您可以在healthcare.gov网站上找到那份清单。但请记住，您是否有资格进行某项检测取决于您的年龄和健康史等因素。关键点二，健康保险公司确实会拒绝这些服务，而原因往往是存在差错。因此，如果您收到本应属于保险范围内的服务账单，请先确认医生诊所或医院是否已向保险公司提交了索赔申请。若已提交，则需查明拒赔原因。

You can find that list at healthcare.gov. Keep in mind though, whether you're eligible for a particular test will depend on things like your age and your health history. Takeaway two, health insurance companies do deny these services, and often that's because of an error. So if you get a bill for a service that you think should have been covered, make sure your doctor's office or hospital actually submitted a claim to your insurance first. If they did, then you find out the reason for the denial.

关键点三，登录保险公司官网提出申诉。通常您有180天的申诉期，需准备包括申诉信（简要说明异议理由）、病历记录、联邦预防性健康指南副本，以及医生出具的医疗必要性证明等文件。在等待答复期间，联系医疗机构财务部门告知您正在申诉，此时切勿支付账单。关键点四，若保险公司两次驳回申诉，可申请由中立第三方进行外部医疗评审。

Takeaway three, go to your insurance company website and file an appeal. You typically have up to one hundred eighty days to do this, and you'll need to compile some documents including a brief letter explaining why you disagree with the denial, your medical records, a copy of the federal preventative health guidelines, and a letter from your doctor stating why the care was necessary. While you wait for an answer, contact the doctor or hospital billing office and tell them you're disputing the denial with your insurance. Do not pay the bill at this time. Takeaway four, if your insurance company denies your appeal twice, you can ask for an external medical review, which will be done by a neutral third party.

评审结果具有约束力。关键点五，若索赔仍被拒，可根据收入情况申请医院财务援助，询问现金支付能否获得折扣。也可与医疗机构协商分期付款方案。切勿使用信用卡支付医疗债务，否则将丧失特定信用保护并承担高额利息。

The results of that are binding. And takeaway five, if your claim is still denied, see if you qualify for financial assistance from the hospital based on your income and ask if they'll give you a discount for paying in cash. You can also set up a payment plan with the medical billing office. Don't put the debt on a credit card. You'll lose certain credit protections and have to pay a lot of interest.

您是否有关于医疗系统导航的问题或经历？这可能成为《医疗援助热线》后续节目的素材。通过本期节目说明中的链接即可分享您的故事。本期《生活指南》由西尔维·道格拉斯制作，塔尼娅·英格利希编辑。

Do you have a question or a story about navigating the health care system? It could be part of an upcoming installment of Health Care Helpline. You can share your story by following the link in the show notes of this episode. This episode of Life Kit was produced by Sylvie Douglas. It was edited by Tanya English.

视觉编辑贝克·哈兰，数字编辑马利卡·加里布。高级监制梅根·凯恩，执行制片贝丝·多诺万。制作团队还包括安迪·特格尔、克莱尔·玛丽·施耐德和玛格丽特·索里诺。工程支持由斯泰西·阿博特和杰伊·西兹提供，事实核查泰勒·琼斯。

Our visuals editor is Beck Harlan, and our digital editor is Malika Garib. Megan Cain is our senior supervising editor, and Beth Donovan is our executive producer. Our production team also includes Andy Tegel, Claire Marie Schneider, and Margaret Sorino. Engineering support comes from Stacy Abbott and Jay Sizz. Fact checking by Tyler Jones.

我是玛丽埃尔·塞加拉。感谢收听。

I'm Mariel Segarra. Thanks for listening. On

每周五的《The One A》播客致力于帮您拨开信息迷雾，聚焦新闻要点。通过我们的周五新闻综述与您共度周末，聆听深入报道本周重大新闻的记者解析。每周五准时加入我们的新闻综述。欢迎收听NPR与WAMU联合制作的《The One A》播客。

Fridays, the one a podcast is all about helping you cut through the info fog and get to what's important in the news. Close out the week with us on our Friday news roundup. Hear from reporters who've been embedded with the biggest news of the week. Join us every week for the Friday news roundup. Listen to the one a podcast from NPR and WAMU.

我有点怀念回到学校的日子。我是说，那时会被指定阅读一些很棒的书，然后还有时间讨论它们。这感觉就像一场梦。如果你也有同感，NPR的每日一书栏目有一整周对高中课程大纲中重要作家的访谈，包括托妮·莫里森、桑德拉·希斯内罗斯、杰森·雷诺兹等等。

I kinda miss being back in school. I mean, you get assigned to read great books, and then you have time to talk about them. It seems like a dream. If you're in the same boat, NPR's book of the day has a whole week of interviews with authors big on high school syllabi. Toni Morrison, Sandra Cisneros, Jason Reynolds, and more.

所以，请在NPR应用或任何你获取播客的地方收听NPR的每日一书播客。

So listen to NPR's book of the day podcast on the NPR app or wherever you get your podcasts.

世界新闻很重要，但有时感觉离我们很遥远，而在《世界现状》播客中并非如此。通过遍布全球的记者，你将直接听到美国贸易行动对加拿大和中国的影响，并认识一位从墨西哥街头清洁工变成流行歌星的人物。我们不需要周游世界——我们本就身处其中。每周工作日，请收听NPR的《世界现状》播客。

World news is important, but it can feel far away, not on the State of the World podcast. With journalists around the world, you'll hear firsthand the effects of US trade actions in Canada and China and meet a Mexican street sweeper who became a pop star. We don't go around the world. We're already there. Listen to the State of the World podcast from NPR every weekday.