Insurance for Chronic Pain Procedures and Surgery
Medical insurance usually aims to provide help to patients for their required treatments, but in some cases, they do not agree with the doctor’s recommended treatment. Here, patients have the right to appeal a denial, and that can be done through communicating all the facts to the insurance company effectively.
Communicating with the Insurance Company
Health insurance policy is a contract between a person and an insurance company about health care and services the company would provide. Following this policy, a relationship between an insurance policy and a person goes in this manner:
- Getting the complete paperwork for the recommended treatment from the doctor to take pre-certified services from the company.
- Insurance company acknowledges your treatment approval or denial and after the treatment is done, the insurance company pays for the expenditures as per your health policy.
There are cases where the corporation rejects to cover the treatment due to different reasons like treatment not being covered under a policy, surpassing of benefits level, the treatment being considered investigational or unnecessary by the company. In some case, the company includes limited treatments for only a few diagnoses. In such situations, if a person is provided with accurate information about claim denial, then he can reverse the claim rejection as people are allowed to reassess or review any decision taken by a company.
Appeal Process for Working with Insurance Company
The process of appealing varies from company to company, but, there a few basic rules that are followed by the entire industry. There are three levels of appeal. In the first level, appeals are handled and progressed by the appeals' staff or the medical director who rejected the claim. In the second level, it is reviewed by the medical director who wasn’t a part of the original decision. In the third level, it is processed by a third party who collaborates with an external expert physician.
When to appeal and when not to
The first thing while starting to appeal is to determine if an appeal is required in a case or not. For this, a person should thoroughly go through the denial letter. If the company is asking for more information, then just providing additional information that matches the company policies is enough.
There are a few conditions in which a person should not appeal like when the company has denied the coverage of the treatment procedure or the person has surpassed the benefit level. The conditions where a person should appeal is when the company has denied different treatment procedures from the one that the physician has recommended, or company has denied because of the unavailability of the treatment’s necessities.
Writing the appeal letter
The appeal letter is the most important thing while appealing for a claim denial. Physicians write this letter, but in case, you are doing it yourself, here are a few guidelines:
- The letter should be simple, concise, and informative with a pleasant tone.
- Mention the urgency of treatment in bold along with all the reasons about the company covering your treatment.
- All information should be explicitly provided like all treatments tried, clinical data of case, treatment consequences on company’s expenditures, physician contact information, and part of denial letter that you are appealing for. (in case the whole letter is not appealed)
- Also, the letter should be revised by your doctor. It is advisable to send a letter through certified mail after keeping all records with you. Do be in touch with the company and make sure they have received the appeal.