Watching patients struggle with health insurers’ refusal to cover treatments can often be excruciating for providers. Anna Matthews describes strategies that increasingly better educated patients are using to appeal payors’ denials in the Wall Street Journal. (“Pushing Back When Insurers Deny Coverage for Treatment,” 9/25/08).
First, Matthews, recommends, patients need to discover “what led to the insurer’s decision, and keep a careful paper trail.” Patients need to review the particular insurer’s procedure for appeals, and then to demand documentation of why coverage was denied. Second, patients need to establish proof that the treatment sought qualifies for coverage under their health plan. Third, patients may need to appeal to the state if the insurer rejects their appeal. Matthews also highlights helpful online resources, such as the Kaiser Family Foundation website and the Patient Advocate Foundation. In addition, she recommend the state advocacy resources compiled by Families USA. Sometimes employers will provide assistance; otherwise, patients can seek help from Health Proponent, Patient Care, or or a similar organization.
Recommended Action: Advising patients on how to challenge insurers can be time consuming for providers, who have enough struggles of their own in dealing with insurers. One upside of the trend towards consumer-directed care is patients who have the knowledge and resources to pick their own battles with payors. Providers can should have suggestions for patients to educate themselves and be able to challenge insurers directly.
Harry Nelson is a partner in Fenton & Nelson, LLP, a law firm that counsels healthcare providers on business and compliance issues. For additional information, please contact Fenton & Nelson at harry@fentonnelson.com
©Harry Nelson 2008
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