Tools to Overcome Medical Insurance Denials

By May 26, 2018 February 12th, 2020 Article

Monthly Premiums, Co-pays and Out-of-Pocket Expenses are some of the familiar terms you may have heard of if you have private medical insurance.  But what happens when you are doing your due diligence and protecting you and your families health, but your insurance provider thinks the necessitates are…..unnecessary.

That is exactly what I have been going through since my daughter was added to my private insurance plan 7 months ago.  Once upon a time, she received Supplemental Security Income(SSI) and if you’re not aware, as long as you are receiving at least $1 in SSI payments, you automatically qualify for medicaid which 99% of the time will cover everything you need.  If you’re wondering why doesn’t a child with a severe medical condition have SSI anymore…well my friends, that would be because I work full-time.  There are income limits and guidelines, and once you’ve surpassed the amount….that’s it.  The coverage with medicaid goes out the window all because “you make too much”.  There are alternatives to this and I’ll explain that later, but for right now, I’ll give you some tools that I have used to overcome the hurdle of a medical denial.  If you’re not a reader (like myself), click this link to watch my YouTube video on how I’ve been conquering this!  Click here to watch.

Don’t Take No For An Answer

chairs daylight designer empty  I’ve never worked in the insurance field, but my wild imagination allows me to assume there is a meeting room and a white board.  On the white board, there is a “yes” and “no” column.  Do you see where I’m going with this?  These “insurance health experts” go through different scenarios and literally say yes or no to covered expenses.  Now I know this is probably not the real way insurance companies make their determination, but my imaginative thoughts sound somewhat realistic….right?  Ok, maybe not.  Nevertheless, no matter how they do it, don’t take the first (or second, or third..) “no” for an answer.  In the insurance world, your disagreement with their “no” equates to an appeal.

Case Manager = New Best Friend

two person shaking each others hands  If you’re like me and make frequent trips to hospitals and/or specialists, it will be a good idea to have a case manager on speed dial.  You can find a case manager either directly in your practitioners office or you can inquire at your hospitals information desk.  During the appeal process, your case manager will become your voice.  They will submit all the necessary documentation that is needed for the insurance company to review.  Sometimes it may be a letter, other times, it will also include medical records (as supporting documents) to get that “No” turned into a “Yes”.  Even if you are a new patient to your doctor, as long as the case manager knows the history of you (or your child’s) condition you should be in good hands for re-determination.

 Can I Borrow That??

Borrowing  Lets say your new best friend/Case Manager has submitted an appeal for durable medical equipment (DME).  What happens during the re-determination period of the appeal?  Are you to just sit and twiddle your thumbs in anticipation of what you need?  Absolutely not!  Ask your doctor if they have loaner equipment.  You may be surprised to find out some doctors have trial equipment that you could utilize to get you through!  They will have you sign a loaner equipment agreement for a period of time and this should get you over that wait period while the insurance company is making their new decision on coverage.

Never Ever EVER Give Up

never give up  When you have put on your boxing gloves and stepped into the ring with the insurance company as your opponent, you will get tired.  You may feel like throwing in the towel and giving in….but that is the worst thing you can do!  There are so many circumstances and conditions that these insurance companies are not aware of, and it is up to YOU to let them know that you are here to go all the way to “round number never”.

What Else Can I Do?

Most states have programs such as model waiver that you can apply for.  The only caveat with some of these programs is they usually have a waiting list and it make take a very long time (as in years) to start reaping the benefits.  But don’t fret, there are also organizations, such as First Hand Foundation, that provides funding for individual children—both domestically and globally—who need assistance with clinical necessities, medical equipment and travel related to care.

Have you experienced a medical denial?  I’d love to learn what tools you used to overcome it!  Let me know in the comments down below.  Watch my latest video to see how I’ve done it ♥