What do you do if insurance companies are denying coverage to patients?

My experience has been more from the mother of a patient with a TBI. You just have to dig in and gather all the pertinent information you can. You rally your providers to support. You have to do the work, because the insurance company expects that most will not bother to fight, to appeal. It is much easier on them and more profitable to deny for the smallest loophole. one that they love is that the device or therapy is "experimental" even though it may have been around for 10years. Gather the criteria needed from the insurance company and policy directly then match up what you have and go after what you need. Make it where they can't refuse.

The problem often arises when the facility sends the insurance company incorrect or erroneous information. It is the responsibility of the patient advocate to coordinate with the facility to ensure that the paperwork is accurate. They must act as the liaison.

First thing to do, is to understand why the patient is being denied access to a particular treatment. From there one ought is to review the benefit entitlement of patient and decide whether a case is to be appealed or not.

Understand the plan limitations. If if it is not a covered benefit then it will always be denied. Asking for a plan exception would go to the individuals HR. The entity paying the costs are the only ones who can decide coverage - 70% of working adults that is the employer. It is a rare thing, 'if we do it for one person, we have to do it for all'. Only a first level appeal is mandatory. Make sure to send in any & all additional information that was missing from the original request. National guidelines are the same for initial requests & appeals. Peer to peer conversations are not designed for the patients doctor to provide additional clinical information. That must be in writing & in existence at the time of the initial request.

Identifying and understanding the root cause of the denial will take a pivot role here. If it's coverage related Denials before we proceed to the next step, check if the patient has eligibility with that payer. If eligible then we can check if are there any limitations for the coverage like maximum benefits reached for a particular service or if the billed CPT is related to the global procedures. In addition, we need to check if the given services are covered under the patient plan, example: the member might have MEDICAL coverage but not dental. If any particular services need any modifiers and any specific conditions to be covered. we need to analyze with the 360 degree to understand the denial and then take appropriate steps.

Especially for patients with rare diseases, the challenge is to find the right arguments/evidence for support. Even the medical community is very weak in this respect and you also have to find a supporting doctor who can help you with the appeal and explain the facts of the case to the insurance company "simply" as to why these patients now need special support, although the literature on rare diseases is just as lacking as the knowledge of the decision-makers in the health insurance company about rare diseases.

I had my own experience with insurance company after my cardiac issues and most of them deny any insurance to me. I feel that vulnerable are more exposed to vulnerability instead of social responsibility of offering some protection to them. Ultimately money wins over humanity.

After EVERY service you have that is billed through insurance...review your Explanation of Benefits. This document will outline the billing codes, what was covered, what wasn't covered, and your out of pocket cost.

I think the barrier of documenting sufficiently is often the enormous pile of paper you gather throughout weeks or months. I can tell from my own experience after my ACL rupture: Take a scan of each and every document you receive. Nowadays, you will even be able to search for text in those scans. Remember that having everything in paperform is a good start, but chances are high you won't find what you need in the moment questions arise... So i would say gather documents digitally and try to categorize it accordingly to avoid confusion in the future

If care ir services medically necessary, you gather as much medical evidence from literature sites that support your appeal, state what was tried and failed and as needed go through the necessary lines of appeal allowed by health plan. You may even want your pay for a 2nd opinion if you cannot have an IMR ( independent medical review- by insurer or state regulatory agency such as Dept of Managed care in Ca)

When faced with insurance denials, filing a thorough appeal is crucial. Drawing from personal experience, I once overturned a $90,000 denial based on a doctor's speculative note. The process involved meticulously gathering evidence to dispute the unfounded claim and submitting a detailed appeal, underscored by a strong cover letter advocating for an independent review. This year-and-a-half battle not only taught me the ins and outs of the appeals process but also underscored the importance of self-advocacy. The effort was immense, but the victory was immensely gratifying and educational, reinforcing the power and impact of standing up for one's rights in the healthcare system.

File an appeal - I've been denied before and it was totally an error on the part of the insurance company. So gather your evidence and call them. Be kind!!!

File an appeal: If you believe the denial is incorrect, you can file an appeal with the insurance company. Follow their specific appeal process, which may involve submitting additional documentation or a letter explaining why you disagree with the denial.

In my ???? experience as a #nursepsychotherapist, having a letter written by the provider to the insurance company on behalf of the client is a good start. Also, if the client is comfortable ask the client to discuss the unfounded denial with the person or team who negotiates the insurance to advocate on their behalf. If all of that fails, ask to have their appeal escalated to the appeals team for review and also to the Ombudsman of the company.

There are usually two internal appeal processes you can file with the insurance carrier, before taking action with your State Division of Insurance.

When facing a dead-end with insurance appeals, seeking an external review can be a crucial next step. However, before proceeding to this stage, I often consult with a billing specialist to comb through the details once more, ensuring no stone is left unturned. Additionally, tapping into the collective wisdom of my fellow Board-Certified Patient Advocates provides invaluable insights. Their experiences and knowledge can shed light on aspects I might have overlooked or suggest novel strategies to strengthen my case. This collaborative approach not only enhances the chances of success but also reinforces the importance of a supportive community in navigating the complexities of healthcare advocacy.

I usually recommend that people contact the State Division of Insurance or CMS to review these denied appeals. There are a lot of state and federal regs that protect consumers.

I highly recommend patients to get in touch with patient advocacy groups - they are extremely experienced in these kind of questions as they have supported many patients before. The problem in my eyes is that people don't know about the existance of PAGs...

when you make an external review include all your emails. A phone log of all you calls. Submit redundant copies of every email. And never forget to include your policy! And a list of all the payments you made for your protection. Be as vocal as you possibly can.

My experience with legal action underscores that it's only viable if you have a "slam dunk" case. Why? Because legal fees will likely come out of your own pocket, making the process expensive. Moreover, finding an attorney willing to take on a case without clear, overwhelming evidence in your favor can be a formidable challenge. It's best to exhaust every other option before considering this path. Additionally, there's a significant price to be paid for the mental anguish you'll go through during this often lengthy and stressful process. Essentially, do all you can to avoid reaching a point where legal action is your only recourse.

Legal action is usually a costly endeavor. When battling an insurance company, it can be difficult and expensive to outlast a case that is sometimes drawn out unnecessarily.

In the end, what counts is the patient's well-being or the preservation of quality of life, and the effort and benefit for the patient should be weighed up (on a case-by-case basis) as to whether the David versus Goliath battle is worthwhile. This should be decided by the patient/family, as they are fighting the battle "against" the insurance companies. Not trying at all is not an option, especially as there is support from patient organizations that can also help you and may also have the right contacts in one direction or another.

I would question if this is actually helpful for you as a patient. The second you have a severe illness, the last thing you want is being part of a legal battle.. but this depends on the exact context..

Give everything you have to the attorney and keep all of the attorneys billing records so you can ask for those legal fees from your I dirsncr company! At this point the more documentsyou have, the better.

Clear and above all simple communication with patients is the key to any joint commitment. Supporting the patient requires the same shared understanding of the process or intervention. The affected person, who is already struggling with the disease, should clearly understand the steps, opportunities and possible success or failure in order to avoid further frustration or mental stress.

While it may seem coddling to some, the patient needs to be directly involved and their experience validated in order to survive the process of appeals to its conclusion. An insurance denial for treatment of any condition is an incredible blow to a patients' self worth. Many will already have struggled through being ignored by doctors or having their symptoms dismissed due to unrelated or even complications from the condition they sought treatment for in the first place!

When faced with insurance coverage denials, we have acute situations that require an immediate reaction but it is also vital to adopt a proactive, long-term approach. We can also identify general gaps in coverage (e.g. for a specific condition) and aim for a change by gathering evidence and justifying the necessity. Engaging stakeholders such as patient groups, pharmaceutical companies, doctors, and researchers amplifies the case's strength. Armed with a coalition of supporters and compelling evidence, engaging health insurers in negotiations becomes feasible. The collective weight of support makes it challenging for insurers to dismiss the case, increasing the likelihood of policy change for broader and sustainable insurance coverage.

In my experience there is often an issue with coding. Many times the ICD and CPT codes don’t align to meet criteria or the CPT code is not the correct code. Verify that the Dx and billing codes are correct and meet criteria for payment. It is important to also verify that the CPT code and medical records match.

Each situation is unique, and it's important to carefully assess your circumstances and seek professional advice when dealing with insurance denials.

In my experience with US and Jamaican health insurance, I can say there are gaps in patient/client education. Policies are sold but the effort to relay the benefits and exclusions require amplification. Too many patients are unaware of the details of their coverage and, outside of those cases that truly warrant an appeal, patients often have expectations/assumptions that do not become informed stances until a crisis arises. A proactive measure that can better position both insurers and the insured is education (in the simplest forms). Policy terms need to be reiterated in layman terms. I believe this can help to better manage and mitigate the number of appeals insurers face.