The Health Insurance Fight Continues

“For many years I have been researching health insurance information in the quest to help women and men who are trying to purchase health insurance coverage due to an existing medical condition.  Another insurance topic that will be covered in this article is for the patient who is in the process of appealing their health insurance payment denial notice. Here are some more updates concerning this important issue.” – Hope Waltman

Overview 

1.  Know what procedures are covered by your insurance policy.  Ask the health insurance company for a copy of your policy and contact numbers.  Make sure you get information explaining what is the proper format for appealing or challenging a health plan decision.  Ask your Human Resources Department personnel for a contact list in case you need to contact them.   

2.  What information is needed before you contact the insurance company?  If you receive a denial statement the first thing to do is collect all documentation that pertains to your case.  The insurance denial paperwork should list a contact name and phone number to call.  Keep detailed notes concerning the name of the person you talked to, date, time, and what was said during the discussion.  Create one file for all this information. 

3. Some medical companies and/or physicians have Patient Coordinators located in their offices who can answer questions, obtain medical articles, and may even help you prepare your appeal package.  

Talk to your physician about the denial and he/she may want to call your health insurance company to see what can be done to correct the insurance company’s misunderstanding concerning the medical procedure and how the procedure will help your health.  The physician may also be able to supply the insurer with current information on the durability of the procedure, other insurance company names that cover the procedure, etc. 

4. What if your denial is not overturned?  After you talk to several people on the phone and the denial is not overturned you have the right to file a written appeal.  Before starting this process ask the insurance company for a copy of your records so you know exactly what they have in their files concerning the issue.  The file should contain the health plan’s description of why the medical claim was denied.  Follow the insurance company instructions on how the insurer wants the appeal letter and supporting attachments sent back to them. 

Claims that were denied due to ‘medically not necessary’ status will require a copy of the following (use a highlighter to mark the areas on the article that pertain to your case): 

a.       Medical records should include all test results that pertain to this medical situation.

b.      Explanation of why another procedure was not considered or failed for your specific situation.

c.       Physician letter explaining ‘why’ you needed this treatment and its benefit to your health. 

Claims that are marked ‘experimental and/or investigational’ will require that you show why the treatment is now medically accepted.  Medical journal articles, articles, and/or study results explaining the effectiveness of the procedure will need to be copied and attached to the appeal letter. 

5. What is the timeframe for the appeal process?  Insurance companies have a reimbursement denial policy of a specific number of days to appeal.  Make sure you know what that amount of days is and make sure you meet the deadline plus provide enough background material to justify why your denial should be changed. 

6. Contact your state legislature to find out if your state lawmakers have enacted a version of the Patient’s Bill of Rights.  This bill gives the patient the ability to ask for an independent medical review for denials as well as questions concerning access to out-of-network providers.  Many lawmaker’s staff may even help you by getting in touch with personnel in their state government who can provide you with more information to help you prepare for your appeal process. 

7. Contact your federal legislature to see what is available at the Federal Government level.  (Example:  Uterine Fibroid Research and Education Act of 2005 [H.R.3034.IH] Congresswoman Stephanie Tubbs Jones, Democrat - 11th District – Ohio – The Library of Congress Thomas)

8. In some cases patients have decided to contact a lawyer to help with their appeal. 

9. Sometimes after winning an insurance denial your hard work may pave the way to make the health insurance company reconsider the procedure coverage and make it a paid covered procedure. 

10.  If you win you appeal case – what can you do to help others?  

Most important - Please remember that one person can make a difference!  

1. Talk to your state legislators about your appeal process and how you won the case.  Some lawmakers may even be aware of other residents who have won similar cases and are trying to find people in their state who are willing to work on creating an organization or help in pushing a bill.
    

2. Lawmakers usually will keep your information on file and watch to see if the health insurance company only pays for the coverage when the patient fights the denial.  They may even investigate why the medical procedure isn’t paid for all of the clients in that company who had the same procedure.
    

3. By working with your state legislators patients may even be able to get laws changed in their state that require the health insurance companies to cover specific medical services (example:  infertility tests/treatments, acupuncture, fibroid treatments, less invasive procedures, etc.).

Some website research links that may be helpful: 

http://clerk.house.gov/ - Federal Government

http://thomas.loc.gov/ - The Library of Congress Thomas 

http://www.hopeforfibroids.org/legislationhome.html - Legislation (uterine fibroids) information

www.healthinsuranceinfo.net - A consumers guide to getting and keeping health insurance is available for all states

www.naschip.org - National Association of State Comprehensive Health Insurance Plans (High Risk Pools)

www.aic.org - National Association of Insurance Commissioners

http://www.kff.org/consumerguide/7350.cfm - Consumer Guide  (PDF) to Handling Disputes with Your Employer or Private Health Plan, 2005 Update.  The Kaiser Family Foundation and Consumers Union released an updated guide to help consumers through the process of resolving disputes with their health plans.     http://www.kff.org/consumerguide/upload/7350ConsumerGuidev4_080805.pdf

http://diabetes.org/advocacy-and-legalresources/healthcare/insurance.jsp - Health Insurance Information for People with Diabetes

http://www.hopeforfibroids.org/insurance.html - High Risk Pools (State Insurance offices), samples of appeal letter and personal letters, and more

http://www.cahi.org/cahi_contents/resources/pdf/MandatesInTheStates2007.pdf - Council on Affordable Health Insurance

http://www.ncsl.org/programs/health/hmolaws.htm - States independent review of denied benefits (charts) - National Conference of State Legislatures

http://www.npaf.org/state/state-by-state.html - State health care information, National Patient Advocate Foundation website

http://www.patientsactionnetwork.org/index.aspx - America's Patient Action Network - American Medical Association (AMA)

Online Health Care Complaint Form – Contact the State Attorney General Office

COBRA - "Health Benefits Under COBRA" contact U.S. Department of Labor at 1-800-998-7542 or 1-866-4 USA DOL. 

http://www.ncbi.nlm.nih.gov/sites/entrez/ - PubMed Medical Journals

http://www.fda.gov - FDA website
 

Home | Contact |  Dentist | Gynecologist | What's New | Site Map
Interventional Radiologist | Insurance | Research | Cosmetic Surgeon
Men | Women

Refer to Top