Fighting for Benefits and Coverage

by Alyssa Quintero on Sun, 2008-06-01 07:13

Getting benefits and coverage from insurance companies and federal programs shouldn’t have to be a battle, but sometimes it is. To win, it pays to know every detail of your policy and benefits plan like the back of your hand.

Understanding the plan’s policies, benefits and eligibility criteria before you file a claim can save you a denial and some headaches in the long run.

And if you’re denied, knowing your policy will enable you to make a stronger appeal by referring to specific sections, or reciting actual language in the benefits plan.

Some basic tips:

  • Read the insurance and benefits plan carefully.
  • Understand the eligibility requirements in order to continue receiving full benefits.
  • Understand any specific requirements for filing an appeal, especially the number of days you have to file an appeal.
  • Consider submitting forms and letters via certified mail to ensure they arrive in the correct place and on time, and to have a record of your correspondence.
  • Keep a log of all contact, and be sure to jot down dates of phone calls and names of people with whom you’ve spoken, and keep a file of sent e-mails and subsequent replies.
  • Follow up. Don’t wait a month before calling again or sending an e-mail or letter. Be persistent!

It’s all in the language

The language used in physicians’ letters of medical necessity and appeal letters can mean the difference between approval and denial.

Certain words or language may trigger either coverage or denial, so focus on the medical issues behind a request. Some doctors don’t mind if you draft a letter of medical necessity, and get his/her approval and signature.

It’s important to do your homework, says Martin Burkhardt of Baldwinsville, N.Y. Burkhardt, 66, is in the process of waiting for Medicare to approve his doctor’s request for a power wheelchair. His doctor submitted a lengthy, detailed letter explaining the medical necessity of a power wheelchair, and his staff included relevant reports about his condition, as well as a copy of the doctor’s notes and a prescription.

Set out to prove medical necessity from the get-go; don’t wait until your claim is denied. However, if you receive a denial letter, your doctor and his staff may be able to help you sort through the reasons why a claim was denied, and help rewrite the letter to ensure a better chance of being approved the second time.

While you’ll encounter doctors who’ve written letters of medical necessity several times over, don’t take it for granted that they know best.

The doctor must make a stronger case than the person at the insurance company who’s reviewing your file. The point is to make it hard for the insurance company to say no a second time.

Adele Abramowitz, whose son Jason has Duchenne muscular dystrophy, says that every piece of equipment he uses initially was denied, but the denials eventually were reversed and approved.

“I appealed and got Jason’s doctors to write letters. If they felt that they couldn’t write the appropriate letter, I wrote the letter, and had them read and sign,” Adele Abramowitz says.

“It’s sometimes not what you ask for but how you ask for it. If you ask for a shower chair, you will not get it because it’s not medically necessary to take a shower. But, if you ask for a commode rehab chair, you’ll get it. It’s all in the language.”

Unfortunately, you can’t make one call and expect someone else to do the work for you.

“Don’t take no for an answer the first three times, and if you get denied, request documentation to show why you don’t qualify for a program or service,” Abramowitz recommends. “Get written proof, and ask to see where it says in the program’s regulations that you don’t qualify.”

I’ll see your denial and raise an appeal

It can be useful to explain the progression of the disease in the letter, because it’s not certain the person reading the file is knowledgeable about ALS.

Mark Airel, 43, of Liverpool, N.Y., was denied four times for a power wheelchair before he finally was approved for a Permobil C300 with tilt and recline.

“The insurance didn’t think he needed it at the time,” says Mark’s wife, Patti. “Once the doctor wrote out all of the terms explaining Mark’s progression, especially that his legs were weakening, and said that he’d need it soon, that took care of it. The doctor explained that with the progression of ALS, Mark may walk one day, and he may not be able to walk the next day.”

Patti says that insurance companies “really don’t understand the progression of ALS.” For instance, the insurance company said it needed more scientific proof that a power wheelchair would benefit someone with ALS. So, in his e-mails to the company, Mark included the definition of ALS in every message.

In more specific terms, the doctor wrote another letter of medical necessity, explaining that Mark needed a power wheelchair instead of a manual chair because he can’t use his arms, and he needs trunk support.

“Make sure the doctor says exactly what he means, and make sure he spells it out in language that a child can understand,” urges Patti Airel.

Danny Dandignac of Leander, Texas, received a diagnosis of ALS in 2000, and he advises people with ALS to always challenge denials from private insurance or government programs like Medicare and Medicaid.

“They make their profit by denying you services,” says Dandignac, 49. “They rely on the fact that more than half the patients that are denied never call them on it. You might have to appeal several times, but there are avenues available. Knowing what you’re entitled to is your best friend.”

Dandignac suggests anticipating that the insurance company will deny the most expensive items or attempt to replace them with cheaper items. That way, the letter of medical necessity covers all the bases with very specific information and details.

If you threaten a lawsuit against a private or government insurance program, proceed with caution. Lawsuits are pricey and lengthy, and it may not be worth it in the long run. And if you’re bluffing, be prepared for the insurance company to call your bluff.

One strategy is to copy your attorney or legal advocate on appeal letters and all other written correspondence with the insurance company — a subtle approach that may grab the company’s attention.

Finding help

If nothing else works, contact your state department of insurance, which offers resources for consumers. You can file a request for assistance in resolving an insurance problem, as well as file a complaint against an insurance company.

Your state’s Protection & Advocacy System (P&A) also has the authority to provide legal representation and other advocacy services for people with disabilities.

And, if you’ve been denied a claim for assistive technology and other related durable medical equipment, many P&As help people obtain AT devices and services through the Protection & Advocacy for Assistive Technology (PAAT) programs.

When hiring a private attorney, find one who specializes in disability-related issues. An elder-law attorney can help you wade through confusing insurance policies and federal benefits programs. The National Academy of Elder Law Attorneys offers a searchable state directory of member attorneys, including those who are certified elder-law attorneys (CELA). To learn more about other legal aid programs, see “It’s All in the Plan,” October 2007.

Local Agencies on Aging and Aging & Disability Resource Centers also can provide benefits counseling. While they can’t provide legal assistance, staffers will examine your case, find out what’s missing from your appeal and provide advocacy services.

Alyssa Quintero
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