Insurance Claims: Don’t Take No for an Answer

by Christina Medvescek on Thu, 2004-04-01 16:41

Last fall, Catherine Wolf, 58 and a nine-year ALS survivor, won a war with her insurance plan over long-term nursing coverage. Wolf, who is vent dependent, now has insurance coverage for round-the-clock skilled nursing. The experience taught her valuable strategies for fighting insurance company denials.

The keys, say Wolf and her private attorney Mark Scherzer, who works with New Yorkers for Accessible Health Coverage, are: dogged persistence, documentation, and “don’t believe everything you hear.”

Catherine Wolf
Catherine Wolf

Winning the war

Insurance companies most commonly deny requested items because they’re “not medically necessary” or “not a covered charge.”

Experts note that while some denials are legitimate, others are due to coding or paperwork errors, or to differing interpretations of what your condition requires. Occasionally, they’re just a brazen attempt by the insurer to hang on to its money.

No matter the reason, insurance companies count on the fact that most people don’t appeal a denial.

Appealing isn’t easy, but then again, neither is ALS. Here are a few hard-won tips:

Know your policy: Wolf was told by her insurer and her corporation’s human resources department that her preferred provider plan (PPO) didn’t cover long-term skilled nursing. “This turned out to be false,” she says via e-mail from her home outside New York. “Don’t believe everything you hear. Demand documentation. I sound militant but it’s best to be polite and establish good relations. Put all requests in writing and mail them ‘return receipt requested’ so you have a paper trail.”

Even if it turns out the requested benefit isn’t covered, it doesn’t hurt to ask the insurer to cover it in your case. This strategy works best if you document how it will save money in the long run, and if your employer is large enough to have some clout with the insurer. A lawyer can help make this case most effectively, says Scherzer.

Know the law: Aspects of ALS care, such as deep suctioning, giving medications when the patient isn’t able to indicate consent, and chest physical therapy, require a skilled professional under Medicare guidelines and some state laws, says Wolf. “If you’re requesting skilled health services, find out from your state health department who is allowed to administer the requested services.”

Also determine whether the insurance company employee who issued the denial has a medical license. Some state laws require a doctor’s denial on items like power wheelchairs or some medical procedures.

Get an effective letter of medical necessity: Wolf’s insurer claimed her nursing care was “custodial” rather than medical and denied it as “not medically necessary.” It’s critical in this case that a doctor writes an effective letter of medical necessity.

“Some doctors write angry letters to insurance companies saying basically, ‘How dare you treat my patient this way?’ But that’s not medical facts,” says Scherzer. Letters should include: the specifics of the patient’s condition; why the requested coverage must be delivered as prescribed; why it can’t be done another way; and the costs of a worst-case scenario.

If the patient has communication difficulties, doctors should indicate that as another reason skilled nursing is medically necessary. “Patients can’t always self-report symptoms, side effects, skin breakdown, etc.,” says Scherzer. “Even if family members can learn (to give care), many patients are more safely cared for if someone with more training is observing them.”

You can offer to help your doctor write the letter, and to mail it once it’s signed. Letters never should state the service would be beneficial for the caregiver as well. Send a copy to the state insurance commission and indicate that this has been done.

Document everything: In arguing for nursing care, Wolf and Scherzer noted that a ventilator failure or mucous plug could happen at any time and lead to death without prompt attention. They documented instances of ventilator failures in the presence of both a skilled nurse and unskilled aides and family members.

They also documented Wolf’s declining communication abilities, requiring a nurse to assess her condition. “Dated notes about your condition or equipment failures, written by a doctor, nurse, aide and family members, are important in establishing your case,” Wolf advises.

Get a lawyer: Every insurance company has a defined appeals process and a lawyer isn’t necessary to use it. But if the appeal is denied and the case goes to court, evidence will be limited to what was presented during the appeals process. “That’s why it’s a good idea to have legal help (during appeal) because you’re creating the record that will be considered by the court,” says Scherzer.

A lawyer also knows your rights. For example, Scherzer requested all medical information about Wolf held by her insurer and employer. This information contained evidence that nursing care was improperly denied. “I didn’t know I had the right to access this information for my appeal,” says Wolf. “A consultation with a lawyer who specializes in health insurance is valuable. It’s not necessary to be near your lawyer. We did everything by e-mail and fax.”

If you can’t afford an attorney, Scherzer suggests consulting with a social worker or health advocate about your options. Check with your state insurance commission to see if an external review agency is available to review your dispute.

Wolf can be reached at cgwolf@optonline.net. New Yorkers for Accessible Health Coverage is found at www.cidny.org

Christina Medvescek
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