August 19, 2017

 
Q. What is the role of the advocate?
A:  The advocate provides denied medical claims help to ensure that you get every penny of what is due you.  What insurance companies won't tell you, we will.  We are on your side.
 
Q.  How much will it cost?
A:  As a 501(c)3 non-profit, there is no charge for the information, tools and other resources including the medical claims advocacy that we offer. We realize that many individuals that are having problems with a health insurer are already financially pressed when they come to us. We serve everyone who calls that we can help. That's our commitment. We do not want money to be an obstacle to people getting the help they need. 
  
Q. Can I claim services not listed in my plan booklet? Yes, most services are coverable or not coverable based on "medical necessity" and whether they are specifically listed in the Limitations and Exclusion of your plan. 
 
Q: Wouldn’t my doctor or hospital be more effective at appealing my denial. 
A: Some hospitals and doctors are very proactive regarding appealing denials. Others set a minimum dollar amount and only appeal denials above that figure. Regardless of whether they plan to appeal or not, it is in your interest to appeal the denial, too, since the health insurance policy is in your name and likely have ultimate responsibility for the charges. Further, some laws require insurance companies to give a more complete response to the policy holder than they give to a third-party medical provider. Therefore, often, insurance carriers take more care when responding to policyholders.
 
Q: Can I claim for services that were denied some time ago? That depends on the timely filing guidelines of the provider's contract and the laws in your state . If they haven't been missed, the appeal will still be considered.
 
Q: I don’t think my insurance company will overturn the denial. Why waste my time?  
A: You may be right. However some insurance regulations and even some independent review mandates requires the policy holder to first file an internal appeal with the insurance carrier. Therefore, this is a prerequisite to getting an outside agency or even, in some instances, prevailing in court. When understood in this context, it it not a waste of time but a beauracratic necessity.
 
However if you do not prevail, you have other options. Currently forty-two states and the District of Columbia have independent review boards. Further, many insurance policies require you to file appeals before litigation is pursued. Once these appeals are conducted, you are free to pursue the matter in court.
 
Q: What types of disputes are eligible for appeal? 
A: Generally, any denial of benefits can be appealed. Confusion sometimes results from the fact that state independent review boards may impose restrictions on the type of provider, the nature of the procedure, or the dollar value of a disputed claim that they will review. However, any denial of benefits can be appealed directly to the health insurance carrier. 
 
Q: Are there any time limits for filing an appeal? 
A: Yes. Your policy may very well set a limit for the time frame for filing appeals. Further, some states' independent review boards require an appeal be filed within a certain period of time after a claim is denied.  Finally, the Employer Retirement Income Security Act (ERISA) which applies to most insurance benefits obtained through a place of employment requires claimants to file appeals within 180 days
 
Q: Will a state independent review board be any more sympathetic to my claim than the insurance company? 
A: Often state independent reviews are conducted by physicians specializing in the area of medicine under dispute. Therefore, they may be much more familiar with the treatment than the insurance company medical director which may be trained in an entirely different specialty. Further, they may be more familiar with the most recent information regarding new or experimental procedures because they more frequently make decisions regarding these types of treatment.
 
Q: Is filing an appeal complicated? Do I need an attorney? 
A: No and no. Just like your insurance contract, the appeal requirements are supposed to be written to be easily understood by people who have never been to law school. However, should you decide to retain an attorney to better protect your interests,  

Q: How long does the appeals process take? 
A: Many state mandates govern how long insurance carriers can take to review internal appeals. ERISA governed plans must make a decision within 72 hours for urgent care claims to 60 days for post service denials. Independent reviews generally take 60 days but can be expedited for pretreatment reviews of an urgent nature.

Q: What are my chances of success? 
A: It is impossible to judge your specific chance for success. However, pursuing an appeal will give you a much better understanding of your insurance contract and assure you that not just one reviewer, but several, reviewed the merits of your claim.  It seems like a step any one in need of denied claims help should want to take.

Q: What if you can't help me?
A:   We have a database of agencies and social service organizations that we will refer you to and may be able to help you.  However, in some cases you may decide that retaining an attorney is appropriate.

    
Health insurance industry whistle blower, Wendell Potter, speaks at the annual OMG! Summit at in Vegas.