Just because your health insurance company says “no” doesn’t mean you have to accept it. You have rights — take advantage of them. Every insurance company gives the insured the right to appeal the insurance company’s denial. There are different levels of appeals. Insurance companies are counting on the fact that you won’t appeal their refusal to pay. The worst thing that can happen to them is that an independent doctor who reviews your appeal will force them to reimburse you or pay the bill. This costs them nothing, but it costs the patient a lot of aggravation, so many patients don’t bother going through with the appeal.
Recently, Mike Barasch had extensive shoulder surgery. His surgeon recommended a healing device which Oxford Insurance deemed “medically unnecessary” and refused to reimburse him for the cost of the device. Mike asked his surgeon to write a letter indicating why the device was medically necessary. He used the letter in his appeal to the insurance company’s denial. The surgeon had a lot more credibility than the insurance company’s in-house doctor. It is not uncommon for an insurance company’s in-house doctor, who reviews hundreds of claims, to be nothing more than a general practitioner. Understandably, his motivation is to keep his job, and sometimes he’s more concerned with saving his company money than doing the right thing.
In Mike’s case, he demanded that Oxford bring the case to an outside doctor for review. The outside doctor was an orthopedic surgeon and he readily agreed with Mike’s surgeon. Oxford was forced to pay for the medical device.
The lesson here is: Don’t take “no” for an answer. You have appeal options and rights. We highly recommend taking a look at: patientadvocate.org. There are examples of appeal letters which you can use. You don’t have to hire an attorney or be an attorney to fight the insurance company denials. Naturally, if you ever have any questions feel free to contact us.