PPOs And Claim Denial

What if my PPO denies my claim?

If your PPO denies you your claim, you go to the doctor and again enlist his support as to why this procedure was necessary, why this visit was necessary and why it should be covered as a medically necessary procedure or visit, that's your best bet line of approach. Secondarily, again write the company and make your own argument as to why this was medically necessary. Best argument is I went there and my skin rash healed. I had this rash for eight months until I got to the dermatologist, and the dermatologist treated it. It's more cost-effective for you to allow me see this specialist and get this done versus going to people that weren't helping me and costing the insurance company a lot of money for eight months. Make your own cost-effective and medically necessity argument to the company yourself.

What information is my PPO provider required to give me if my claim is denied?

If your claim is denied, your PPO provider is required to give you, depending on the type of claim, within a certain number of days, the basis for their denial. And that's the first line of helping anyone that's going to help you determine where you're going to fight. So you want to find out, as soon as you can, what is their basis for the denial. They like to say, "Well, we don't think it's medically necessary at this time." They like to choose these broad clauses that are somewhat meaningless. And so you want them to get as specific as you can as to why the denial has come forth. That helps you to then figure out what you're fighting.

What if my PPO provider claims the cost of my care is 'excessive'?

Based on the locality that you live in. If you're in Beverly Hills or if you're in a small town in Alabama. There will be a different cost associated with the care of your genealogist or your family care doctor. Each insurance company has these reasonable value care assessments they make based on your zip code. And so, you can go to someone in Beverly Hills and the insurance company will say, well we think that they're way to expensive, just because of their location and because of their overhead. And so in fighting that you have to; that's one of those things that before you go there you have to try to find out what they're going to pay for care given. If you go to a world renowned specialist verses a garden variety person, they're usually going to pay on both the same amount of money. By the pre authorization process you can find out ahead of time, what they're going to pay. If you haven't done that and you find out that they have suggested the fifty percent of someone's bill is unreasonable, you again enlist your doctor to help you, because the doctors don't like to be seen as unreasonably extravagant in their cost. And they will usually help you with a letter to the insurance company explaining why your procedure needed all these different costs and that it wasn't that their fee was high.

Is my PPO provider required to grant me an appeal?

Nationally, under some federal laws, you are required to grant a disgruntled insurance person an appeal. And again, remember, this a way to try to solve the problem before litigation and before lawyers, so it's to their advantage to give you an appeal. Now most internal driven appeals could be used as a delay tactic and are usually not going to come out in favour of the patient. But it is a process that a lot of them require you to go through. And on small items, and on some items that are not time essential, it can be a process that does help.

Should I use my PPO provider's formal appeal or review process?

Depending on the dollar value of the claim, if you're out a fifteen-hundred-dollar item or a two-thousand dollar item, the appeal process is probably the most efficient way to start. If you're out a two-hundred to four-hundred-thousand dollar process, it depends if the contract requires you to go through the appeal process, but you don't have to do things that are going to be of no value. Often people will go into an appeal setting and say a bunch of things that they don't understand or know based on the contract, and argue actually against themselves. Those statements get used against you later on if you do choose to go to litigation or hire a lawyer. So you have to be careful about those appeal processes. But generally for smaller dollar items that you could not afford to have extra help on, or that no attorney would want to fight over, like a fifty dollar claim, the appeal process might be your best avenue to give it a try.

What should I do if my PPO denies my claim?

It depends. If it's a medically necessary, emergent type of procedure, try to get that procedure right away and find a way to get the treatment. You don't ever want to delay your treatment and possibly harm your life or end in death because you're waiting to get something covered or not covered. Secondly, you should appeal to them, and get your doctor to appeal, and then you should write to the HMO's CEO. Often you can enlist the help of people in the community, such as a broker or other doctors, to write to the insurance company. The more attention you can bring to your denial the better.

What kind of documentation should I keep relating to my denied claim?

Anything that the insurance company writes to you regarding your denied claim is essential to keep. That is something that can be used back against them. Often they have people that deny something, and these people have never gone any through training as to what's covered. Often they have people that have no legal background whatsoever denying very expensive, very costly procedures and with no medical background either. So sometimes those letters can be the best thing you have to get coverage for yourself, because they've used non-medical and non-legal people to write these letters that are effectively meaningless, but might help you actually get what you need.