Fighting My Health Insurance Company
What is the likelihood my health insurer will reverse its decision?
It depends on the cost of the procedure and it depends on if your contract has a good argument for coverage, if your health insurer will reverse its decision. It depends on a case by case basis and usually the cheaper things are more likely to get covered.
What is the typical time frame for fighting a health insurance company?
If it's an emergent procedure, they have to give you a statement within 48 hours. They have to give you an approval or denial within 45 hours and then offer you some kind of an appeal process, usually with 72 hours. That's again for something that's life threatening. Each state has different requirements, and generally it's a 30-day process that they have to look into it, evaluate it, and then generally issue you another denial.
How can I negotiate with my HMO?
If you get to the legal department of your health insurance company and there's a very ambiguous term, such as "medically necessary," and they're saying it's not, your doctor's saying it is; then you sometimes have a means to negotiate with them. And usually that's going to come best through an attorney, but they may offer you another alternative. They may offer you treatment at another care facility because they have a contract. So, you want to look at your procedure and, "Could I get this done at any other place?" You may also have to give up your first chosen place and go to another facility. So those type of things are depending on where your HMO has the contract. Sometimes you can get what you need, but you might need to go to a different facility because that's where the HMO has the contract. Those things sometimes are negotiable. The negotiation will not come, and will not take place with the person on the 1-800 line. The negotiation sometimes, and the flexibility sometimes, comes with the highest level person in the insurance company such as at the medical director level or the CEO.
How can I negotiate with my PPO?
With a PPO, the same thing. With a medical director, if you're needing someone or a specialist that you don't feel is within their network, and you want them to pay the full reimbursement level of a specialist outside their network, you can talk to them about it. And sometimes, in rare disease cases, they will go and get an individual contract for you, for say your infant, who needs some specialized treatment, and you can go to that specialist. So that's the type of thing where they'll say we don't have someone, and they'll try to argue that their person in network is just as good as the person you want to go to. That's where you say, well this person is better for these reasons, and can you get a contract with this person so I can go there. And sometimes there's flexibility there.
What can I negotiate with my HMO or PPO?
Your options for negotiation with your HMO or PPP are usually different facilities, because someone wants to go to Facility A or Surgery Centre A and they want you to go to B. You're not going to be able to negotiate significant things, but you can always ask, and you can always try. And, again, often on the big ticket items, they know that they're going to face media exposure, they know that they may cost someone in your family a life, they're much more apt to have a discussion. They're usually only going to have a discussion, though, with your representative or with your lawyer. The person who's really ill and denied is not the best person to be speaking to the company. Usually it needs to be a family member or a professional on their behalf because the person talking on the phone is so engaged with the disease, they're so burdened, they're tired, they're ill, and that person just doesn't have the capacity. And they usually give up, and they're not thinking properly, and sometimes the HMO can talk them into things on the phone and get things out of them. So it's best to have a friend, a representative, or a lawyer talk to the HMO on your behalf, if all else has failed on the self-help measures.
What is the likelihood I will go to court against my health insurance company?
Most health insurance companies are going to do anything to keep you from your sixth amendment, right to a jury trial. So the likelihood of you ending up in a jury trial against an HMO is severely limited by their contract. Remember, they don't want to have you on equal footing with them anywhere in front of the normal people that would be on a jury. So the likelihood is significantly limited, because they are going to force you into the arbitration. An individual who is hired to look at your case, who is a lawyer and has that type of background, possibly a retired judge, in some office building. They do not want you to go to the house of public scrutiny with a jury. They fear juries, they fear common and normal humans looking at these cases, because they are normally found to have done it incorrectly. So they will stir you every way possible to get you out of the court house.
How long will it take if I go to court against my insurance company?
If you have an emergency need, they usually have to review it within 72 hours. After that, they usually have about 30 days to give you some form of an appeals process. If it progresses past this point, then there usually is a law suit against them, which is going to take a year to a year and a half. Now, most of that time is going to be attorney time, and in most of our cases, the lawsuit itself other than the trial has taken the client two to three days and out of the year and a half, that's their only involvement. But it's always something that's on their mind, and it does hang over them until we're able to win the case.
When is it time to give up the fight with my health insurance company?
Churchill said, "Never give up. Never give up. Never give up." That's our general position with the health insurance company. However, if it's a small dollar value and you're fighting over the principle of making them pay, you will be able to choose effectively when to give up. After the tenth letter, after the twentieth letter, after spending forty hours on a fifty dollar matter, the person is in the best place to decide that. If it's a costly matter, you, your lawyer and the doctor can discuss your ability to pay, your frustration level with fighting them, and whether or not you want to bring in another professional to take over your battle. It's a case-by-case basis as to when to give up. Occasionally there is something that is not a real medical procedure, that is way out there, having cloves put on your back in Bora Bora. I'll tell people right away, "Give up on that one. It's not going to be covered and there's many other more important battles to fight." There's an occasional crazy issue, but usually the most important things that might help you live, or live longer, or cure a disease are worth fighting for to the very end.
