Insurance Company Letter of Determination
Scenario 2: Your Insurance Coverage Was Denied
Don’t panic. It happens. You can still win, but now it’s time to regroup, rethink strategies, and enlist a new and powerful ally.
You have entered a new stage in the battle - the Appeal stage - with new rules, hidden hazards and sometimes arcane procedures and tactics. Even though you aren’t suing your insurer, it’s time to seek the advice of an experienced Insurance Attorney or Insurance Advocate.
In the same way you worked with your surgeon’s office to meticulously prepare your Letter and Application, your specialized insurance advocate can help you walk safely through the minefield of the appeals process.
What’s essential is to have the appeal done quickly and properly the first time because insurance policies often spell out specific
time constraints for an appeal, and also limit the number of appeals a patient may make. And both limitations are generally held to be legally enforceable. If you wait too long to make an appeal you lose. You use up your allotted number of appeals with ineffective or incomplete efforts you also lose.
So when you get that letter denying coverage, gather your forces, enlist your new allies and act quickly based on an informed strategy that will defeat your opponent with the first counterattack.
The first part of an informed strategy for an appeal is to determine WHY you were denied insurance coverage for your surgery.
Excuse 1: The Procedure Isn’t "Medically Necessary"
If coverage was denied on this basis of “medical necessity,” the insurer’s response is often vague, only stating that the procedure "is not medically necessary" or "does not meet criteria".
The job facing you and your advocate at this point is to force the insurer to specify
how and why it came to this determination. If you haven’t managed to do so earlier, have your advocate demand a copy of the insurer’s criteria of medical necessity. While many insurers are reluctant to comply, at least one state, California (Health and Safety Code section 1363.5) mandates access to these criteria. Your advocate should also demand to know exactly which criteria of medical necessity your insurer claims have not been demonstrated sufficiently.
If it turns out your Letter and Application were insufficiently detailed or incomplete, or the insurer requires unanticipated additional information (e.g. a psychological
evaluation) at least now you know exactly what the insurer claims to need.
Provide the material your insurer says it requires to meet its own written standards. That step alone may make for a successful appeal.
It sometimes turns out that your insurer’s criteria for "medical necessity" conflict with those of your surgeon or the NIH criteria. And maybe those criteria are so restrictive and burdensome that it is difficult or impossible for you to sufficiently demonstrate.
Then it’s time for your advocate to argue that your surgeon’s letter complying with the NIH criteria meets "the generally accepted medical practice" for this procedure. As Mr. Lindstrom points out, "While your insurer has certain rights to set its own criteria of ‘medical necessity’, it does not have the legal right to unreasonably or arbitrarily establish a definition solely designed to eliminate otherwise necessary medical treatment or to deny a claim. I believe that such conduct is bad faith and may, under certain circumstances, be actionable."
more on Insurance
Company Letter of Determination
*TRICARE patients with authorization don't need a prepayment.
Copyright 2005
Professor Rudolf Weiner, MD
About Us / Contact Us
|
Terms of Use & Privacy
Policy |
by OBGYN.net