By Martine G. Brousse
Patient Advocate, Certified Mediator
August 8, 2022
I recently gave a presentation to business folks about Insurance Appeals: why and how should a patient file one. My talk was 30 min. The following Q & A lasted over an hour.
I already knew patients and their caretakers were not filing appeals, but what shocked me the most is that not one of the 35 participants had ever done so. The majority were hearing about this right of theirs for the first time.
WHAT IS AN APPEAL?
An appeal is a request sent to an insurance asking for a review of a decision, of a denial of coverage or of how a specific claim was processed (Explanation Of Benefit).
This is the right of a plan's subscriber, as well as a provider, to ensure that charges ahve been processed - and paid - at the highest rate possible and in accordance to the terms of the policy and legal mandates.
WHY FILE AN APPEAL WITH YOUR INSURANCE?
The 2 basic types of denials are:
Charges were rejected or denied: No payment was issued, and the insurance rejected financial responsibility. The industry's average denial rate is at least 20%. Of those, many are denied in error.
A claim was processed incorrectly: although the insurance accepted responsibility, the wrong rate was applied, a specific term of the policy was overlooked or a legal mandate was ignored.
HERE ARE 7 REASONS TO APPEAL:
1. Rejection for no eligibility:
· Your new insurance plan does not show you as covered, or COBRA has not kicked in (extension of coverage when premiums are paid by the patient instead of the employer).
· Your (new) insurance has not yet received or applied premiums to your account
· If neither the insurance’s Eligibility Dept nor the COBRA administrator can get eligibility established or updated. File an immediate appeal to avoid any lapse in coverage for you and your family.
2. Rejection for no coverage:
· A specific device, item, procedure, service or type of medical care are denied as “not a covered benefit”. What is the exact reason: was the drug denied because a generic version is available? Was the maximum number of visits per year exceeded? Was the device not covered because the diagnosis listed is not specific enough?
· Once the insurance rep has clarified the exact reason, file an appeal documenting why your medical circumstances must override the policy: you are very allergic to the generic Rx, your autistic child needs - and has been prescribed - more than the 12 covered speech therapy sessions a year, the patient has had a stroke and needs a walker to avoid falling while ambulating. Medical records are a must.
3. Rejection for lack of medical necessity.
Has your provider ignored the insurance's requests for medical records? Sending them should resolve the matter. No appeal is needed.
But the office or you may need to file an appeal to obtain a specific authorization or get a claim paid:
· Gather evidence proving this service/surgery/Rx/treatment was the only one advised by your physician(s), the only one safe and effective, or was the last chance for you to regain your health or avoid irreversible damage.
· Always include a letter of medical necessity from your physician (or other treating Drs) and medical records.
You may also have to prove that the specialist you consulted:
· had the best credentials, availability, training, experience for your (rare) condition,
· and that no "in network" or insurance- contracted provider could render the level of expertise or care needed, or could give you a timely appointment.
4. Rejection for lack of authorization
It is not a patient’s job to obtain an authorization for a surgery or “big” services like chemo. Most insurance companies would not allow them to do so anyway.
But if the office or facility decline to help for lesser services, you may need to provide your insurance with the medical records showing why they are necessary.
· Explain that special circumstances prompted action without a pre-authorization: emergency, holiday, outside of insurance utilization management phone hours, remote location, no insurance card on you at the time of ER services, lack of billing staff at the facility or office due to Covid, etc
· If the facility or physician are out of network, explain why you must use their services and theirs only (competence, emergency, etc). Any document from that office explaining they do not accept or bill any insurances should be included.
5. Rejection as "experimental" or "not FDA-approved"
The assistance from your Dr or facility is crucial here. Were you informed that a treatment, drug, device or procedure were not considered Standard of Care in the US? If yes, you may have a hard time winning an appeal but it is not impossible.
· If a Rx off-label use (not yet FDA-approved) has been shown in studies and peer approved medical literature to be safe and effective, you have a chance. Your disease may be rare. You should not be penalized by the scarcity of trials or non-action at the FDA level due to the lack of research or of new drugs being introduced.
· I have won several cases at the State and Federal levels, by proving discrimination against rare disease patients from lack of national interest and research funding.
· Check the current FDA stand on your denied procedure or treatment. Insurance medical policies are not updated quickly, and something denied yesterday may be FDA-approved today.
6. Rejection for geographical reason
All HMO and a number of EPO or PPO plans have exclusions for services rendered out of state or outside your immediate residential area.
Do file an appeal if:
· services were rendered under emergency circumstances
· the out of area/state provider you consulted is the only authority in the country or State for your condition
· this specialist is the only one able to give you an appointment within a short period of time to avoid serious consequences to your health
· the lab you had to use was the only one able to perform the special tests your Dr ordered
· there is no comparable facility or available specialist within 30 miles from your residence. In a large urban area, the 30 miles translate into 1 hour in transit
· your surgery required a high level of care which the local facility was unable to meet
Patients living in rural areas are particularly at risks of such denials. These should be vigorously contested.
7. Processing at the wrong rate
Ah, if I had a dollar for every claim paid at the wrong rate…
Let’s remember that claims are processed by algorithms based on procedure and diagnosis codes and a tax ID number. Whether unintentionally, or due to programming … creativity…, mistakes will be made.
· If a pre-authorization had been obtained and ignored, for coverage or for a special rate of payment, a call to the Claims Dept should get that claim reprocessed. If not, an appeal should be a sure win.
· If a provider or facility were paid as Out Of Network but your policy pays In Network (higher) rates for those specific circumstances, do appeal! Emergency conditions for example are often ignored when most policies cover those services at the highest rate.
· The new No Balance Bill federal law forces many plans to cover certain services and circumstances at the highest rate. Some similar bills at the State level do the same. Your insurance may have to abide by them and an appeal must be filed. Violations can and should be reported to the appropriate authorities.
· A provider may have cancelled their contract. If treatment started when there was one, appeal for “Continuation Of Care coverage” and the higher payment rate. Do show that interrupting or delaying care to look for an other in network provider would negativity affect your health. Insurers routinely continue to cover treatments such as chemotherapy or ABA therapy for an autistic child at the highest rate.
A WORD OF CAUTION:
1. There are so many other reasons to file appeals, and many more where the right of appeal does not apply. (see separate blog covering this topic).
2. Keep in mind that the number of appeals you can file is limited to 2 (with plans administered by the State) and usually 3 with ERISA self-funded plans (administered by the Dept of Labor).
3. I never recommend to file an appeal over the phone with a rep. First, they will write what they understand, not necessarily all you tell them. Secondly, and most importantly, you cannot attach any document, medical record or other evidence to support your appeal. These appeals almost always result in denials. Do not waste your appeals!!
This is where a patient advocate specializing in the billing side of things, and with appeal experience is a great ally to have on your side.
Martine Brousse is a Patient Advocate and Certified Mediator located in CA and the founder of AdvimedPro, which she started after 20 years as a billing manager for physicians.
@ Martine G. Brousse 2022