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David vs Goliath – Appealing heath insurance denials

Posted in Health

“Nobody knew that health care could be so complicated” uttered Donald Trump, in a turn of phrase that will haunt him forevermore.

Try being the insured: undecipherable plan terms, small print that would defy a legal mind and byzantine bureaucracy. And let’s set aside the premiums. My friends in European countries have a hard time understanding how a Western nation of the size and might of the United States could be so poorly equipped to deal with its citizens’ health priorities. And I scramble to provide a cogent answer.

But, for now, it is what it is – made largely better by the passing of the Affordable Care Act a few years ago – and one is left to make sense of the system, working within it to advance one’s personal health agenda.

Sometimes it feels like pushing boulders uphill. After having been healthy for my entire life and barely thinking about my health insurance, in my 53rd year on this planet I had to navigate breast cancer. I am one of the lucky ones: I can afford a pretty good plan, I live in a state that has kept premiums somewhat stable and my local hospitals are top-notch. I was still confronted with a mysterious system that becomes clearer only when something bad happens. Proverbial trial by fire.

Mostly, my care was delivered swiftly, in the manner I chose and was truly excellent. But there were some insurance roadblocks that I felt resentful of being forced to deal with while still aching from the surgery or tired from radiation. Even now, a whole year and three months later, I am still dealing with the aftermath:  billing issues that require more phone calls than it should be necessary and a referral problem at the onset of my cancer that had me resorting to yelling, threatening, pleading and begging in that order. But I have now learnt that with some patience and study on my part, insurance companies can be made to see the light (hopefully, when it’s not too late).

Take my request of having my surgeon review and order my mammograms for the next two years. My surgeon happened to change hospitals about six months after I was under her knife. Apparently, for me to keep on seeing her, I needed a new referral – why, as the records clearly stated she had been instrumental to my care, I don’t know but, at this point, I am not trying to overhaul the system. Just making it work for me. I secured the referral.

A week later, I got a letter from my insurance stating that my request was denied because I did not need a surgeon. Technically, they are correct. I don’t need further surgeries but the bureaucrat who reviewed my case needed only to scroll back to my past twelve months of appointments and treatments to figure out it was a continuation of care.

At the back of the letter, I found instructions on how to appeal the decision. I composed my letter stating the reasons why it was crucial my surgeon follows me up to two years and, while it’s not standard everywhere, it makes sense. The first 24 months after surgery, the risk of a recurrence is much higher and it’s important the person who opened me up can swiftly intervene. At the very least, she knows better than anyone the inside of my breast: any new lump or calcification that might appear, she can better determine whether it’s scar tissue or if further testing is necessary, in the end, possibly saving money to the insurance company.

Here is what you need to know if any of your claims – financial or otherwise – are declined:

  • The first person who reviews them is a non-medical employee who is trained in handling claims, often not the best judge
  • Your appeal will be evaluated by a panel of three, including medical personnel
  • If you are still denied but choose to persevere, your third appeal will be wholly in the hands of doctors.

It pays to keep at it, as maddening as it might feel. Each denial has to be justified so you have the basis on how to handle your appeal. This is particularly crucial for patients who are asking for experimental treatments if they might have exhausted all other options. In fact, there are people who, having had to fight for their care, now extend their expertise to other patients who might not be strong or equipped enough to fight for themselves. It’s a whole new cottage industry.

A brief primer if you need to file an appeal:

  • Do your research. Find precedence and/or reasons why a certain treatment should apply to you
  • State the facts, each based in scientific or medical reason
  • Underline how (if applicable) a certain treatment might save money
  • Keep the tone personal, include a few key facts about yourself, to remind the reader of the real person at the other end of their evaluation.
  • If you are unsure, the doctor who recommended the treatment can come to your aide, either by helping you compose the letter or advocating on your behalf.

In the end, my not so difficult appeal was granted. Three different humans saw how what I was asking made sense. I filed it with a sense of deep satisfaction. Then I picked up the phone and called my surgeon.

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  1. Grazie, vale dappertutto

    April 9, 2017
  2. Alison

    Excellent information, written so well, from the heart. Love your posts!

    March 29, 2017
    • Thank you Alison! I really appreciate you taking the time to lavish compliments!!

      March 31, 2017
  3. when Trump says Nobody realised Healthcare can be so complicated, he is projecting, and what he means is that He never realised that it was so complicated. Presumably because he has never had to give much thought to it as he is so wealthy and his company probably pays his premiums and those of his family. He has really no idea about anything that affects people, because really he does not care about anyone else.

    March 28, 2017
    • What is happening in this country is mind-boggling. Not even the best spy thriller novelist could come with what we are reading every day.

      March 29, 2017
      • that is so true. Of course up to now, movies have always shown America saving the planet. I really hope that happens soon, cos the way Trump is going, it will be an America that kills it

        April 1, 2017
  4. Well done Camparigirl and congrats on a well won outcome. As you note not all patients have the capacity to fight what is a world-wide medical bureaucracy. It is ironic that one needs to be super-fit and healthy plus have the time and resources to take the bureaucracy on and win. You set an excellent precedent.

    March 28, 2017
    • Which is why reasonable countries take a lot of the healthcare decisions out of the patients’ hands by supplying what is needed, when it is needed, no questions asked (and no credit card upfront).

      March 29, 2017

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