How do you navigate your health
insurance? This is a question many
haven’t really faced recently, given the changing climate of health insurance,
with the implementation of the Affordable Care Act of 2010. It’s important as
consumers each of us understand how to ensure we received both coverage and
payment for services covered under the plans we sign up for as individuals,
through our employers, or via government offered insurance.
One of the biggest challenges for consumers
is navigating the claims process. Most consumers of health insurance expect
that their doctors will submit their claims for them. Some doctors will do this, and an additional
fee is included in the doctor’s overhead fees.
However, many consumers are now finding that many of their doctor’s are
no longer submitting claims for them.
However, this isn’t the biggest challenge for consumers.
Advocating with your health insurance company
for payment for services that should be covered under your insurance plan is.
Ensuring you receive payment for medical services covered by your plan and
rendered by your doctor is something that consumers have been fighting since
HMO’s became the standard for health insurance and care in the mid-1980’s.
We’ve all heard stories on the news about
health insurance companies denying claims for treatment of serious diseases,
some denials having serious consequences.
Here’s a short article from US News & World Reports about how Health
Insurance Companies try to drag out the process: How
Crafty Health Insurers Are Denying Care[1]
As consumers, it’s our responsibility to
understand what our Health Insurance Plans cover regarding medical services, and
the associated cost. However, very few
people really pay attention to what their plan covers, and how much the plan
will pay for those services that are covered.
Each type of plan has different requirements that must be met prior to
payment.
So why am I writing about this? Recently I’ve been running the gauntlet of
health insurance claims denial. Havoc, my son has been taking speech
therapy. He has a problem articulating sounds
and words correctly, which makes understanding him very challenging. Typically we only understand 10% of what he
says. His articulation problem is the
result of chronic ear infections as a infant and toddler. Prior to pursuing speech therapy, I contacted
my health insurance company to verify if speech therapy was covered under my
plan.
According to my health insurance plan "
The benefits for speech therapy state the plan will pay benefits for speech
therapy only when the speech impediment or dysfunction results from injury,
sickness, stroke, cancer, autism spectrum disorders or a congenital anomaly, or
is needed following the placement of a cochlear implant." I received confirmation via email
correspondence from my insurance company that this what my plan covers.
In December I submitted the first set of
claims to my health insurance company. I received notification at the beginning
of Jan 2013 that those claims were denied. So, I called up my health insurance
and started asking questions. After a week of badgering - the insurance company
actually told me verbatim what I needed to do to receive payment, based off
Havoc's diagnosis codes (ICD codes).
They told me his medical file had 4 ICD codes, related to his ears and speech therapy (387.9, 382.9, 307.9, 784.59). The even pointed out which ICD code met the criteria above to receive speech therapy benefits, for Havoc. They also told me what language they needed in the letter from the provider to support the appeal of the current claims, and justification for all subsequent claims.
Here's what they told me to have the provider provide, on their letterhead: "Havoc 's speech impediment/dysfunction, ICD 784.59 resulted from a congenital anomaly ICD 387.9 deformity in the ear which is pathological condition of the bony labyrinth of the ear, in which there is formation of spongy bone; may cause bony ankylosis of the stapes, resulting in conductive hearing loss; cochlear otosclerosis may also develop, resulting in sensorineural hearing loss."
So, after receiving this information from the insurance company I contacted the provider of Havoc’s speech therapy, and after discussion – we realized the insurance company gave us an ICD code that was not diagnosed by the otologoist Havoc saw in July 2012 or by his pediatrician. So we decided that was not the best course of action for ensuring coverage of his speech therapy. We decided to continue perusing coverage using the diagnosis code for chronic ear infections, which is the IDC 382.9.
They told me his medical file had 4 ICD codes, related to his ears and speech therapy (387.9, 382.9, 307.9, 784.59). The even pointed out which ICD code met the criteria above to receive speech therapy benefits, for Havoc. They also told me what language they needed in the letter from the provider to support the appeal of the current claims, and justification for all subsequent claims.
Here's what they told me to have the provider provide, on their letterhead: "Havoc 's speech impediment/dysfunction, ICD 784.59 resulted from a congenital anomaly ICD 387.9 deformity in the ear which is pathological condition of the bony labyrinth of the ear, in which there is formation of spongy bone; may cause bony ankylosis of the stapes, resulting in conductive hearing loss; cochlear otosclerosis may also develop, resulting in sensorineural hearing loss."
So, after receiving this information from the insurance company I contacted the provider of Havoc’s speech therapy, and after discussion – we realized the insurance company gave us an ICD code that was not diagnosed by the otologoist Havoc saw in July 2012 or by his pediatrician. So we decided that was not the best course of action for ensuring coverage of his speech therapy. We decided to continue perusing coverage using the diagnosis code for chronic ear infections, which is the IDC 382.9.
I submitted an appeal to have the original
claim re-evaluated base upon chronic ear infections being a “Sickness” and the
direct cause that required Havoc’s speech therapy. This was submitted within the 30-day appeal
window.
At the beginning of March 2013, I received
the response from my insurance company.
“This appeal was reviewed by XXXXXXX, MD, DDS
MBA specializing in DDS Otolaryngology Head and Neck. This decision was based on the XXXXXXXX
policy for Speech-Language Pathology Services.
Per Dr XXXX,
The appeal request and submitted
documentation was received and reviewed, including the speech records from
XXXXXX, the Speech Language Pathologist and the normal hearing tests.
Based on this review, the appeal denial is
upheld. The plan only covers speech
therapy for a dysfunction, or impediment that results from injury, stroke,
cancer a congenital anomaly or autism. Speech therapy is specifically excluded
per your plan documents to treat stuttering, stammering or other articulation
disorders.
Therefore, CPT code 92507 is not eligible for
reimbursement. If you choose to appeal
this decision, it is recommended that you submit for consideration why you
believe the speech dysfunction is a result of injury, stroke, cancer, a
congenital anomaly or autism.
Base on our review, according to your Benefit Plan, under the
Additional Coverage Details section, Rehabilitation Services – Outpatient
Therapy and Manipulative Treatment subsection, this request for payment was
processed correctly.
The Plan provides short-term outpatient rehabilitation services for
the following types of therapy:
-
Physical Therapy;
-
Occupational therapy;
-
Manipulative treatment/Chiropractic care;
-
Speech therapy;
-
Post-cochlear implant aural therapy;
-
Pulmonary rehabilitation; and
-
Cardiac rehabilitation.
For all rehabilitation services, a licensed therapy provider, under
the direction of a Physician, must perform the services.
The Plan will pay Benefits for speech therapy only when the speech
impediment or dysfunction results from Injury, Sickness, stroke, cancer, Autism
Spectrum Disorders, or a Congenital Anomaly or is needed following the
placement of a cochlear implant.
Benefits are limited to
-
36 visits per calendar year for physical therapy;
-
36 visits per calendar year for occupational therapy;
-
36 visits per calendar year for speech therapy;
-
36 visits per calendar year for manipulative treatment/chiropractic
care;
-
36 visits per calendar year for post-cochlear implant aural therapy;
-
36 visits per calendar year for pulmonary rehabilitation therapy; and
-
36 visits per calendar year for cardiac rehabilitation therapy.
These visit limits apply to Network Benefits and Non-Network Benefits
combined.
Because the claim(s) for this was processed according to the above
plan provisions, the original determination remains unchanged, and is
upheld. This decision does not reflect
any view about the medical appropriateness of this service(s). Only you and/or your (or the patient’s)
physician can make decisions regarding proper medical care.”
Receiving this letter was a kick in the gut. I read it and got mad. Then I read it again. After reading it a 2nd time, I realized the insurance company denied the claim for everything but “Sickness”, which should have been covered for the plan. Chronic Ear infections are a “Sickness”. After reading this and discovering that the insurance company wasn’t adhering to the Plan, I decided to have it reviewed by a lawyer for breach of contract. I’ve had enough legal experience to realize I might have a shot at Breach of Contract.
The legal review confirmed that my insurance company was in
Breech of Contract. Booyah! Knowing that
I had a solid case against my insurance company I contacted my Human Relations
Department, and brought them up to speed on the claim. I also informed HR I was considering my legal
options. HR asked me to wait before I
did anything, because they needed to have my company’s legal team review this
to verify Breech of Contract.
Why did my company need to review my denial of claim for Breech
of Contract? Well, when you receive
health insurance from your company, they are entering a contract on your behalf
with the insurance company. So, if I
pursued a suit against my insurance company for Breech of Contract, my employer
would also be a party to the suit.
Health Insurance Companies don’t want to have their clients taking them
to court, especially if they’re a major player like a Fortune 500 Company. That’s not good for business.
Within two days of contacting HR, I received notification that
my insurance company would cover Havoc’s speech therapy. It took me four long months to garner
coverage for a service that should have been approved when it was first
submitted as a claim. This timeframe is
relatively short, given others struggles with claims.
As a consumer always ask what's covered under your plan, and get it in writing. It used to be at the beginning of each New Year the health insurance companies would send you a book of legalese that described in boring detail what was and was not covered by your plan. Now to "save paper" you can access it on line, if you know where to go. Be proactive - find out what's covered, and what isn't - so when you submit claims, and they get rejected - you know how to appeal each claim, and get the money you should be getting for services that are covered. Additionally, as a patient you have the right to know all of your diagnosis codes, and your health insurance company must provide them to you when you ask for them. So start asking and use this as leverage to make your health insurance work for you.
Additionally, you might want to consider submitting your medical claims yourself- instead of having your doctor do it for you. Why? You then have ownership of your health care. Take control of your health from all aspects of its management. Figure out how to make it work for you, not against you, this is just one component of Jack Kruse’s health IPO http://www.jackkruse.com/brain-gut-15-creating-your-health-ipo/
Here are my tips for ensuring your health
insurance covers the services your Plan stipulates.
1)
Know what your Plan Covers
2)
If your not sure a medical
service is covered by your plan – ask in writing for verification.
3)
Keep track of your claims
4)
If your claims are denied contact
your HR department to see if they can help.
5)
Be wiling to consider all
options, including legal actions, sometime you have to go BIG to get the
results you want.
Remember YOU are your best advocate. If you discover you need assistance reach out
and ask for it. You can even ask me, and
I can try to point you in the right direction. My
hope is that others can use my experience and leverage what I’ve learned and
apply it to their own situations. If you
do the research, have the back up material, you too can take down Goliath.
[1]
http://health.usnews.com/health-news/articles/2008/08/25/how-crafty-health-insurers-are-denying-care
