Doctor Discussion Guide
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Medical insurance helps many patients obtain the treatment or surgery they need. There are times, however, when your insurance provider might not agree with your doctor's recommendation. Knowing how to communicate effectively with your insurance company can be the first step toward a successful claim resolution.
Your health insurance policy is a contractual arrangement between you and your insurance company. Your policy will list the services that are covered and those that are not, and both you and your insurance company are bound by the terms of the agreement.
The way your relationship with your insurance company should work is:
Sometimes, your insurance company may not be willing to provide coverage for a treatment or surgery. Possible reasons include:
Insurance companies are required to provide covered members with a process for reconsideration and review of any adverse decision or claim denials. They also must provide information about this review process. When policy holders receive the right information according to the insurance company's policies and procedures, they are often able to overturn a claim denial.
Each insurance company has its own appeals process; however, there are some general guidelines that apply throughout the industry.
Typically, there are three levels of appeal:
First, carefully review your denial letter to determine why your claim was denied. If your claim was denied because your insurance company needs more information, you may not need to appeal, but simply gather the information and submit it according to the company's policies and procedures. Your physician or his or her office staff may be able to assist you if needed.
You probably should NOT appeal if:
You may want to appeal if:
If you do decide to appeal, you will need to communicate clearly your reason(s) for doing so, and be able to produce documentation to support your claim. This might include a Letter of Appeal (from you or your doctor) and a Letter of Medical Necessity (from your doctor), and any other paperwork your insurance company may require. In instances where new technology is an issue, you may want to include copies of peer-reviewed journals and clinical outcomes data regarding the treatment that has been denied coverage.
First, refer to your insurance policy booklet and talk to your insurance company representative about your claim, then:
You also may enlist the help of your physician and/or his or her office staff in resolving your claim. Ask your doctor to call your insurance provider and speak directly to the medical director or case manager involved in your claim.
If your medical insurance is provided by your employer, contact your company's human resources department for assistance. If your company's insurance provider is refusing to cover a medical treatment recommended by your physician, your human resources staff will want to know. Ask for their help in handling your appeal—sometimes a phone call from your employer to the insurance company can make a difference.
There are also some government agencies that can help. If you believe your insurance company is not furnishing the guidelines you need, you can contact your state's insurance commission, your local Division of Consumer Affairs, or Office of the Ombudsman for assistance.
A clear, concise appeal letter is one of the most important elements of your submission to the insurance company.
Your physician may offer to write the letter, but if you are writing your own, here are a few guidelines to consider:
If you would like to write an appeal letter but don't know where to start, here's a sample appeal letter.
Medtronic is focused on improving patient access to our therapies and technologies. As a result, Medtronic’s Spinal and Biologics business provides a service, Therapy Access Solutions (TAS), to assist in navigating the authorization and appeal process with payers. This program offers information, training and support for our customers. Contact the TAS staff at (866) 446-3873 for assistance with prior authorizations, denial management and appeals, office staff education and training, and product information.
The intent of this information is to provide you with the general framework and processes you should be aware of when appealing a coverage denial by your health insurance company. Each insurance provider has specific policies and procedures for handling subscriber/member appeals. These policies and procedures vary from company to company. Please refer to your insurance policy or contact your insurance provider's customer service department to obtain specific information about its appeals process.