Monday, February 10, 2014

How I went up against our insurance company twice, and won

If you knew me in person, you might think I can't "go up" against anyone. I'm nice like that. But when something goes wrong and it's not my fault, or when someone attempts harm on another that doesn't deserve it, well, I kind of boil up inside. 

So, when my insurance company - who will remain nameless for the sake of not wanting to be hand slapped (or worse), denied my son's treatment at his current RTC(Residential Treatment Center)... well, I boiled over. It kind of went like this:
  1. I got the news from my son's treatment center that his care had been denied by our insurance company. Now this is a very big deal. Treatment at this center is approximately $15,000.00 per month. Yes, that's fifteen THOUSAND dollars PER MONTH. A month of treatment goes by remarkably fast. Now try paying that out of pocket.
  2. I let the natural course of things take place by filing an appeal with my insurance company.
  3. The appeal was also denied by said insurance company, so
  4. I organized myself by compiling dates, facts, doctor's reports, anything I could get to support my son's cause, and 
  5. I wrote a letter that felt like I was writing a term paper for my college "major". This time, it took me over a week to write this letter. When I did this last year, it took about 2 months. Okay, this isn't exactly my area of expertise.
  6. And then I took that letter and all my supporting reports, and I reported my insurance company to the California Department of Insurance.
Once you report your insurance company to the Dept. of Insurance, they will review your case and the supporting information you send them, and determine if your case is eligible for an Independant Medical Review. If they determine it is, your case will be assigned to an impartial investigative reviewer who is an expert in their field. In my case, it was a board certified psychiatrist, actively practicing in his field, who also holds special certification in the areas of treatment under review. 

And, guess what? My appeal worked! The independent review determined that the services were and are medically necessary for treatment of my son's medical condition, AND the insurance company's denial of services will be overturned. Woop woop!

Even though I don't want my son to be someone who needs extensive care - in fact, I really just want him to be normal and healthy. BUT, if he must remain in extended care and treatment, he is entitled to the services we pay for through our insurance company. That this insurer denies necessary treatment for my son is appalling to me.

That any insurance company denies necessary treatment, or gives people the run around so they just give up, it makes my blood boil. It is just not right.

And I know this happens all the time. 

So, if this is something you are dealing with, I encourage you to take action now. Don't think it's impossible (that's how I used to think). Let me tell you that you can do this too. 

In fact, I have been successful not once, but twice. Last year's denial reversal amounted to an approximately $40,000 award towards our son's care!  

In an effort to help you out, I want to offer the following tips that might give you some guidance:
  • Get super organized. Take over the kitchen table if you need to. Just start early enough so you can finish by dinner :o) Organize all your papers, letters, reports, denials, etc. Put them in a binder, or several binders in order of the dates, most recent first. Use post it note tabs to help label your papers.
  • Write out a Timeline of everything that has happened. I started with my son's prenatal care (since that's when the trouble began). Make 2 columns with the dates in the left column, and the event in the right column. Get as specific as you can with the details. This counts when the reviewer is looking over your case, and wants to gain understanding of what you or your family member has dealt with.
  • Ask the treating doctor to write a letter on your behalf stating why the treatment IS medically necessary.
  • Write a letter to your state's Department of Insurance. I contacted them ahead of time so I had someone lined up who could help me. I directed my letter to this person. In the letter, be very specific about what you need; tell them why the denial is wrong, and the reasons why this type of care is medically necessary. End the letter by specifically stating that you want the denial overturned and for the insurance company to pay for the necessary care. 
  • Compile your letter, denials from your insurance company, doctor's reports, and your timeline together. Make copies of everything you send. (Put these copies in your notebook for safe keeping) Make sure you fill out any necessary forms the Dept of Insurance requires. Send your packet to the Dept. of Ins. via certified mail, return receipt requested.
  • If this seems overwhelming to you, you can hire a lawyer to help you prepare a packet that you can submit to your state's Dept of Insurance. 
Good luck, and remember: You can do this!

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