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How to Play the Insurance Game and Win

One of the biggest topics in the news over the last several years has been the topic of healthcare, and no wonder with the costs of care rising like never before in history.  Recently, there was a meme that came across my Facebook news feed that had the actual medical bill for the birth of a child in 1942.  The total bill had been just $24.24, which is not even enough to cover that nice little hospital gown let alone the room, physician’s fees, medications, and all the other items that go along with delivering a healthy baby.  But, given the fact that giving birth in 1942 carried a much larger risk to both baby and mother than today, most parents are willing to pay the exorbitant costs, especially seeing that insurance companies usually pay out a large portion of that bill.

But, what happens when the insurance doesn’t cover the treatment that is being suggested? Today, insurance seems to decide the course of action and how we manage our healthcare decisions.  And unfortunately, insurance is not in the business to save lives and cure diseases.  They are in business to make money. This means that no matter how much your insurance company seems like they are serving you, really you are serving their bottom line by not utilizing their services

For kiddos with special needs, this is not an option though.  So what are parents to do when the necessary treatments and services are being denied by the insurance?  For most special needs parents, this can be a heavily closed door! It can be painful to know that there is something out there that will help your child, but due to finances it is not an option.  Believe me, I truly know how this feels!  Not many of us can afford healthcare without the help of insurance, but there is a light at the end of the very long tunnel that is insurance coverage.

Today I will share with you some tips, strategies and terms that really help insurance companies loosen the purse strings.  While I am not in the know on every single insurance policy in America, I am a special needs mom who has worked in medical billing and insurance.  I know the game, I know how to play, and often times, I win.  I would like to share this information with you, so that maybe you can start winning some battles with your insurance company too.

Have a Good Contact Person

When dealing with your insurance company regarding services you would like covered, one of the best tools you can have is a good contact person on the inside.  If the first time you contact the insurance, things do not go well, try calling back and speaking with someone new.  When you find that person that seems genuinely interested in helping your family, ask for their contact information, and tuck it away for future use.

Recently we had an experience where we were trying to get vision therapy covered for our daughter.  The eye doctor could not get the necessary documentation to the insurance company, so we offered to submit it ourselves.  However, when we tried to submit the paperwork to the insurance, we were originally told that the original documents needed to be snail mailed.  This meant that we would lose the original and have no proof that we sent the paperwork, let alone that the insurance company received it.  When we tried again with our better contact, we were given the fax number and were able to submit everything the very next day.  This lead to a much quicker approval, and our daughter is on her way to receiving vision therapy services very soon.

Speak The Language

When I became a special needs mom many years ago, I had to learn some new languages, and one of them was how to speak insurance, which has helped me immensely in getting services covered for my kids. Coming from the medical field, I had a big head start on the insurance lingo, and there are a few terms that insurance companies love to throw around as reasons not to cover certain services and treatments.  However, if parents learn to use these terms appropriately, they can actually become an asset and help get coverage that was previously denied.

Prior Authorization

Many of  you know about prior authorizations, but for those of you that don’t, it simply means that the insurance company wants to see all records and documentation regarding a potential claim to see if it meets the coverage criteria of the policy.  Basically, they want time to see if everything being requested is both necessary and covered. The problem occurs when parents okay a treatment only to find out that it required a prior authorization before the insurance would cover the services, because this means that the insurance company doesn’t have to pay a dime toward any services that were provided before a prior authorization was approved.  It could leave parents with a hefty bill to pay, and the worst part is that none of the charges will go against the policy deductible either.

For this reason it is extremely important to make sure that what is being recommended does or does not require a prior authorization.  Quite often this is something that the service provider can check on for you, but if not, you can contact the insurance using the phone number provided on the card.  It is not the responsibility of the provider to know whether a recommended treatment requires a prior authorization, so they do not need to suggest this prior to services.  It is important to remember that you always have the right to request a prior authorization be done so that you will not be presented with a nasty surprise the next time you open your clinic statement.  If a prior authorization is necessary, do not consent to services until you have heard back from the insurance company.

Normally the provider will submit all necessary paperwork for the prior authorization, and will also receive the denial or approval letter that should include a detailed explanation of the decision. You have the right to know why a claim has been denied, and can ask the insurance company to provide you with this information.  You may then use this information to make adjustments to the treatment plan or gather necessary documentation with the hope of getting the amended prior authorization approved.  As many of you know, this process can take a really long time to complete, so patience will be necessary.  I sometimes wonder if insurance companies draw this process out longer than necessary and make things extremely complicated simply to see if we will get tired of fighting and simply give up.

Medical Necessity

One of the best ways to push a prior authorization into your favor is to use another favorite insurance company term, medical necessity.  What does this mean?  In simple terms, it means that a medical professional qualified to make the determination, has qualified the procedure as being critical to the health and well-being of the patient.  In even simpler terms, its necessary.

Insurance companies love to deny claims because of these two little words, that is unless you can learn to use them too.  Basically, when an insurance claim is denied because it as been deemed not medically necessary, what they are truly saying is, “Even though the policy covers this, we do not have documentation that your condition warrants us paying for these services.”

There really is a very easy solution to this denial.  Get more documentation to the insurance company.  This is when you contact your provider and ask them to send in additional documentation to prove that this service is medically necessary and why.  It is very difficult for the insurance reviewer to deny a claim for a covered service when there is solid documentation that what is being asked for has been determined to be necessary by a medical professional.

Please don’t feel like you are inconveniencing your provider by asking for this.  They do this all the time for lots of patients, and these days, it can be as easy and as simple as an email to the insurance provider.  In most cases, providers are happy to do this, because they quite often feel like the insurance companies tie their hands and prevent them from effectively treating their patients.  They want their patients to receive good care, and if it means taking a few minutes to send out a simple letter, they are usually quite willing to do it.

Non-qualifying Diagnosis

This is another favorite of insurance companies, because not many people are going to argue with this one.  It’s not the insurance companies fault, its your child’s diagnosis, right?  It doesn’t seem like something that can be argued, but it can.  Quite often this comes down to simple medical coding.  There is a whole language that I still have not learned call ICD-10, which is the language of medical service coding.  These codes are entered on insurance claims and are read by computers not people.  So, if the computer sees a certain diagnosis code paired with a certain treatment code, it may deny it simple because the programming tells it to do so.

If this is the reason for the denial there are a couple of options that can be tried.  One is  to call your provider to ask them if there are other codes that can be tried.  More often than not, there are.  If not, your provider can still be of help in getting the service approved.  You may have already guessed it, documentation.  For example, if your child needs Occupational Therapy (OT) to help treat their Autism Spectrum Disorder (ASD), insurance companies may deny this simply because OT is not usually something required by patients with ASD.  Maybe your child is having difficulty with skills of daily living due to their sensory aversions, and OT can really help with this.  Have your provider send in documentation stating this.  Many times insurance companies will not argue with a well written explanation from a physician even if what is being asked for doesn’t usually fit with your child’s diagnosis.

The second avenue to try, is reviewing the diagnosis and needed service with your insurance.  The first place to look is of course your insurance documents you were given when you enrolled.  For many of us though, this can be very confusing and not very helpful.  If your insurance booklet is not getting you anywhere, call your insurance company directly.  Ask them if there are better codes, or what diagnosis would allow the services to be covered.  Many times they will be honest and tell you.  Then relay this information to your provider to be used on the claim.

Get Creative

Try to think like an insurance company.  I know this is a tall order, but getting creative just may mean that your child can have the services that they deserve.  Maybe you have a wonderful speech therapist at your child’s school, but you would like your child to receive these services through the summer as well.  The therapists within your network don’t seem to understand your child, and you have been given the name of a really good therapist outside your network.  Try working with your child’s primary physician to provide good documentation why the out-of-network provider would better fit your child’s needs.  We have done this on more than one occasion and have been pleasantly surprised by getting an approval.

In the case of vision therapy, our provider is out-of-network and will not work with filing to our insurance.  Our son was able to go through a full year of vision therapy and our daughter is going to begin next month simply because we got creative.  To get these claims covered we will have to pay the bill in full at each visit, and then submit the claims directly to our insurance company ourselves.  We will then be reimbursed for the portion of the claim that is covered by insurance.  Yes, there is an initial outlay, but we used our cafeteria plan to pay the initial fee.  And knowing that our children will be able to receive the necessary services is well worth the extra work in filing claims and being in close contact with our insurance.

Parents, when you find yourself in a place where the one thing that stands in front of your child’s treatment is an insurance denial letter, please do not let that be a permanently closed door!  There are so many ways to turn that denial into an approval, and the sad fact is that most people don’t know that these avenues exist.  Use these strategies so that you can play the insurance company’s game and win!

If you would like to learn more tips like these or be invited to join me in a future free insurance training session, you can subscribe using the link at the bottom of the page.

And if you have a tip to get the insurance to cover things they have previously denied or are usually not covered, please share them in the comments!

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