Great suggestions that worked. I wanted to add some additional strategies that helped me to successfully win administrative appeal for denied insurance benefits. Mine was for surgery recommended by my dr. While I know it's most convenient to talk w/the ins on the phone and agree that's the place to start, I also strongly recommend the following as well: (1) get the names & phone # of everybody you speak with and ask when they will let you know the outcome, (2) always write a summary of ALL of your conversation(s) w/date, names, and phone #'s in case you need to follow-up with a formal written appeal, (3) always get the name of the Medical Director who is overseeing what is goes on. That's the person who is making the most money by denying benefits. (4) Read your policy. It will say something like they will pay when 'medically necessary' as defined by them. If they continue to deny benefits, you'll need support by your physician to document your medical record and to contact or fax info to the insurance. (5) Federal or state regulations & laws governing insurance vary esp if it's private insurance btw individuals & an ins company. Complaints against the insurance company may be regulated by a state insurance commission. Benefits and appeals process may be different if provided thru employer. My employer was the federal govt thru a federal contract that was exempt from state regulations. I had to exhaust all administrative appeals first. In desperation, I enlisted my congressional representative to inquire on my behalf as well as the govt's contracting official. After 7 weeks and 2 administrative appeals, my surgery was finally approved w/the 3rd appeal, not because I was any worse off than other patients my dr was treating. We were certain it was because my HMO knew that I wasn't going away quietly. I followed-up every conversation w/a certified ltr & simultaneously faxed to the Medical Director that summarized our conversations and my description of denial upon my health. The ins industry does not want state regulators or anyone else scrutinzing their actions.
I think your logical approach is fantastic, but perhaps we should come up w/a strategy for others without having to fight one claim at a time. Some years ago health insurers were denying in-hospital maternity benefits kicking women out of the hospital hours after their babies were born. It took an act of Congress passing a law to protect women and their babies.
When one person is unjustly denied medical benefits, we are all at risk for the same.
Great comment/post/advice. Thank you!
Believe me, I agree when you say, "perhaps we should come up w/a strategy for others without having to fight one claim at a time." The problem is that Congress is far more likely to act when it's women and their babies. We've been fighting triptan limitations for years, but haven't found a solution to that one yet either. If you come up with a way to fix this for everyone, I'll be right behind you!
Teri
Hi Teri!
When I ran out of unemployment, I opt not to renew my Topamax. My cost was over $177. We have no income now. Our insurance we were buying ourselves we are canceling at the end of November. I figured I'd rather put $700 into meds and office visits instead of insurance that make me pay a co pay and deny me meds like Lyrica that is FDA approved for fibromyalgia.
I'm going to apply for those free programs where you can get free meds. Don't know if I can get Norco but it will be one of the few I pay out of pocket.
I want to join this benefit program called Alliance that will pay back some of the costs of office visits. It's not insurance but more like a "club." They have a lot of other benefits as well.
All in all, it'll be cheaper for me to NOT have insurance than to pay insurance, deductibles, and co-pays on top of that. I'm still trying to get my husband to see that until SSDI approves us, it's the only way we can keep going.
My two or three cents worth *G*
Mary aka GeekyGranny
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Teri,
I just wanted to let you know that after working in Healthcare for over 10 years, I know a lot about insurances. They try to get out of paying for everything. I collected from all insurances, as well as Medicare, and Medicaid billing and Collections. It's terrible! It's a big game with them, and the providers. The patien's suffer the most. I loved the challenge at first, but looking back, it never gets better. They deny many claims and some patients get stuck paying lots of money out of pocket! I hate insurance companies with a passion. It has to get better, that's all I can say.
Hi, Denise,
Thanks for commenting on your experience. I really have to agree. Our son is a doctor, and I have friends who are doctors. I see what they go through dealing with insurance companies.
Not quite the topic of this SharePost, but there are quite a few Migraine specialists who no longer participate in any insurance plans. Dealing with the insurance companies was causing them to have to add more and more staff members, which drives up the cost of care. So, quite a few have simply stopped dealing with insurance companies, which lets them keep their fees lower.
As for Medicare and Medicaid, it's just absurd. They pay so little that it often costs the doctors more to provide the services than they're paid for them. And, it's going to get worse. In 2008, the government is reducing Medicare payments to doctors by over 10%.
I don't often mention this, but I worked in claims processing for one of the biggest insurance companies for two years. I was young and naive. Looking back, I really shudder.
Teri