Friday, March 29, 2013

Taking on Health Insurance Companies - David vs Goliath

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. 

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

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. It makes me sad and mad that you would have to go through all of that to have his therapy covered. I ran into a similar situation years ago, while I was working full time. I found it very difficult to get anything accomplished with my insurance company, it became my full time job. After I battled with them for 10 months, and me filing a complaint with my employers HR department, did this matter happen to get "resolved" in a matter of days. I'm glad you got what your child deserves. This is great information that everyone should read and USE if and when they need to. Thanks for sharing Gretchen

  2. Thanks Dannielle!

    I'm hoping that this does help others out there.

  3. When most people would shrug their shoulders and not put up a fight with their insurance companies when discrepancies arise, it's refreshing and truly inspirational that there are people like you. You sought for professional help when you thought that you needed one. And because of that, the problem is fixed legally. This is definitely a good read. Thank you!

    Janay Stiles

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  15. " 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. "

    This booklet is known as the "evidence of coverage" (EOC) andis the real contract between you and your insurer, even though you never saw it or agreed to it in truth. Laws vary by state, but if you make a written request for a copy of the EOC in print the insurer has to provide it within a certain number of days. When you get an insurance denial, always look in the EOC to see if the specific thing is excluded or addressed. Insurers often miss what is in the EOC.

    My daughter was denied continued speech therapy for a genetic disorder because it was deemed that "three months was enough". When I pointed out the EOC said speech therapy was covered as long as the patient was "making progress toward measurable goals" they backed down, and she continued speech therapy for another year.

    Most people don't know the EOC exists and don't appeal denials, but it's almost always worthwhile to appeal, even to the next level or two if necessary.

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