As an amputee, you need all the support you can get when navigating the world in a whole new way; this includes navigating through the tricky world of healthcare. We all know that prosthetic bills are not cheap and getting the right insurance coverage for you can help your finances in a big way. When a health insurer rejects your claims for coverage on certain types of prosthetic treatments, it can get quite frustrating and confusing, especially when you unexpectedly need to cover costs. Don't lose hope though, as you still have the chance to appeal a coverage denial and here’s how you can do that.
Why You May Be Denied
1. Billing mistakes or incomplete information
This can be a result of your prosthetic facility submitting an erroneous minor claim. Call them up immediately to clarify if they missed some details or if it's an issue that can be resolved over the phone. If so, the good news is that they’ll only need to re-issue the claim. Make sure that the resubmission is done in a timely fashion and don't hesitate to follow up regularly. Timing is everything!
2. Treatment is not medically necessary
You need proof that your medical provider believes that the recommended treatment is medically necessary; get a second opinion if needed. Make sure to ask your doctor or healthcare provider to have all the pertinent information and reasons you need the treatment are documented.
3. It's experimental treatment
Computer legs or microprocessor knees used to be flagged as experimental treatments. These days, your insurance can cover experimental treatment if you or your prosthetist can ascertain the following:
- It's medically necessary and considered as standard procedure by the medical community
- It's the only treatment that will work for you—show them proof of other prosthetic treatments you've tried and why they haven't been effective
- It's treatment that's been covered by the same plan for other patients with the same medical condition. Your prosthetist might have more information regarding this. You may also ask around in online forums like Reddit to gather more information about your case
4. Out of network
Get a pre-approval letter if your plan initially did not have access to a provider with the necessary specialty in-network, or if it took too long for you to acquire an in-network provider. Again, make sure that you have the proper documentation for your condition so that you can justify why you couldn't afford to wait for in-network support.
5. Your policy was cancelled for lack of payment, or your employer shifted insurance providers
If you failed to make a payment on time, there was a payroll error, or if you opened a new bank account and forgot to inform your insurer, simply explain why it happened and again, provide documentation. Also state that you've been a member of ABC insurance for X amount of months or years, and that you've always paid on time. You can ask your insurer to make an exception and reinstate your health plan.
Employers may also change insurance carriers, and if the last day of coverage under your previous insurance company was right before the date of delivery, it can prove to be more challenging to overturn the denial. It helps to contact your HR department to know their timeline as it pertains to changing health insurers so you can hold off on receiving prosthetic services.
How to Win Your Prosthetic Insurance Appeal
Though it may be counterintuitive, approach each claim as if it's going to be denied. This way, you can plan early and prepare yourself with all the documentation you'll need. Arm yourself with information and don't hesitate to work closely with your prosthetist when prepping for your "Medical Necessity" claim. Physicians must specifically include all relevant information, such as their professional opinion regarding the timeframe for when you can reach your functional potential.
Maximize your chances of successfully battling insurance denials by making sure your healthcare provider describes your condition in great detail. Some factors to consider are:
- Do you experience local and/or phantom pain?
- Do you have wound healing issues?
- Is your residual limb experiencing skin irritation, chafing, or infection?
- Does your residual limb have volume changes or swelling?
- Did you ever experience muscle atrophy or osteoarthritis?
- Information like gait, balance, coordination, and arm/leg strength should also be included
- Your prosthetic performance and its condition, as well as why it needs replacement (if applicable)
Again, it's all about the paperwork! Ask your physician for a copy of your comprehensive evaluation and give your prosthetist a copy as well. Bear in mind that it's better to "over document" rather than to give bits and pieces of information. Make sure that your prosthetist has what they need before a claim is filed to help all parties save time and reduce back and forth. Incomplete paperwork may result in delays so always supply them with as much information as you possibly can. The fewer questions the insurer has, the better!
Check (and double-check) your benefits
Check with your insurance provider to confirm your benefits in detail, or better yet, read up on the benefits found in the booklet given to you when you received your insurance plan. If you prefer to do it over the phone, call the toll-free number at the back of your medical card and ask the following questions:
- What's my coverage?
- Are there any deductibles and has my coverage been met?
- Do I have a share in cost?
- What's my maximum out-of-pocket expense?
Don't be afraid to ask as many questions as possible. That way, you’re armed with information.
Document, document, document
Get everything in writing. Though this can be tedious, it’s highly advised to conduct exchanges in any form of writing—email, fax, or even snail mail. Filing for an appeal over the phone can be risky because it's never really documented, but if you do transact over the phone, make sure you write down the customer representative's name, position, and phone number, and listen in to hear if they're typing to create a record of your call. If you're issued a reference number, don't forget to write this down as well in case you need to follow up.
Keep things organized
These insurance companies most likely receive phone calls, claims, and appeals on a daily basis. Keeping all your information organized will make it easier for them to track your records and accommodate your phone call if you have reference numbers or other specific information on hand. "I think I called some time ago and spoke to a representative" doesn't help so much, versus "I called last ABC and spoke with Ms. XYZ about my appeal on 123."
Make sure all of your paperwork and notes are neatly filed. Staying organized will keep you calm and save you time, rather than scrambling to find details on scattered pieces of paper.
Know why they denied your claim
Once you receive your Statement or Explanation of Benefits (EOB), call your prosthetic facility and ask why your claim was denied (as previously mentioned above). Remember that denials are recoverable with the proper tools and that you're not the first and last person to have an insurance claim denied. Stay calm and organized and bear in mind that there's always a solution to everything.
Get rid of the easy problems first
Most times, the easiest explanation can be your top solution. It could have been a simple data-entry error like a misspelled name, insurance ID number, or the incorrect service date. Proof-read and double check any errors you may find throughout your documentation. If there is one, your insurance company can correct it before you proceed with appealing. If your prosthetic provider committed the error, they can fix it from their end and resubmit the claim.
Follow up and pay attention to the timeline
It always helps to take note of when you need to follow up and be aware of the dates when you can call again. If your prosthetic company tells you that they should have more information after 1 week, jot it down on your calendar and give them a call once the week is up.
Be kind to the messenger
It's understandable to get scared or frustrated when your claim is denied, but always remember that the person at the other end of the line is simply the messenger and can be your ally. Treat them with respect and try not to channel your frustration towards them.
Take your case further
If your insurance company denies your claim, you still have another chance to change their minds. The Affordable Care Act/"Obamacare" requires states to set up an external review process for denied medical claims. Check if your state operates under the new guidelines as well. If your insurance company denies your claim, an external review by an independent review organization (IRO) will be conducted, to determine if you claim was rightfully denied or not.
If at first you don't succeed…
Apply, re-apply, and apply some more. Insurance companies try to spread risk and keep as much money, for as long as they can "adjudicate a claim". In the long run, they'll eventually pay up and record it as a loss in their spreadsheet.
As long as you're armed with information and support, the chances of your claim denial being overturned increases. There are times when insurance companies deny your claim in bad faith, and this can get quite frustrating and confusing. Always remember that you have the right to appeal and that third-party reviewers can help justify your claim on top of your documentation and exhaustive evaluation.