YDAS

   Frequently patients are denied treatments and medical equipment due to erroneous reasoning by the initial examiner. The patient is in an unfair position due to:

1. Patient could be in pain, suffering or sick at the time of the request,

 2. Patient does not routinely file for insurance advantages,

 3. Patient’s area of expertise is outside the health care world and the patient depends upon the knowledge of those employed to serve in the patient’s greatest interest, not the employers sole interest.

   Here are a couple of of the guidelines to understand when dealing with insurance firms:

1. Pre-authorization versus Pre-determination Usually an insurance employee will routinely deny treatment or durable medical equipment employing the phrase ” the treatment, equipment was not pre-authorized consequently we deny payment”. Pre-authorizations are NOT LEGALLY BINDING but can be intimidating when a patient first hears it. Now if the denial is based upon Pre-determination then that can be binding but it also is a binding commitment to “PAY A Particular Quantity OF Dollars FOR A Specific CODE OR PIECE OF EQUIPMENT”. The issue for pre-determination is not coverage, but quantity to pay for the coverage contracted for.

2. Words are not legally binding from the insurance carrier. Essentially if you do not have it in writing then it digresses to “he said, she said” and is not provable or binding. The very best policy is to put all dealings in writing and/or summarize any conversations in writing and send by certified mail to the insurance organization, certified mail, to the individual you spoke with. If the individual you speak with does not offer name or mailing address then note in the written correspondence being sent to the insurance carrier.

three. There are many laws to protect patients, with ERISA being the strongest, but there are also conflicts between whether or not state or federal law applies. Federal law applies to self insured plans and State law applies to fully insured plans. If State law is applicable then you generally apply the law of the state in which the insurer has it’s principal location of company, where incorporated, and where the patient resides, or where the injury/accident occurred.

4. Regulatory laws initiated by specific legislative bodies need compliance. Most states and the federal government have granted authority to regulatory bodies to set rules, rates, compensation to institutions such as Industrial Commissions, Worker’s Compensation etc. and the rules of those bodies apply to patents and insurance firms alike. The appropriate to sell insurance in the specific state or federal regulatory body involves the granting of permission to do so which also includes certain contractual rights and obligations in dealing with patients.

5. Typically a fundamental denial will be “Out of Network”. The insurance businesses are obligated to supply patients with competent medical providers, not the best medical provider. If the firm, hospital, clinic you want to use are accentuated that is a prima facie case of allowance if the services are not reasonably obtainable within the network the insurance carrier chooses. If the use of one insurance provider that is in network constitutes an unreasonable burden then the patient could request an exception due to X,Y,Z. If there is no provider in network that provides the identical or reasonably same items/services then out of network providers need to be approved. If the patient has visited, or examined the proposed in network provider and does not feel the provider is qualified or competent then that argument should be employed in requesting an alternate out of network provider.

6. Insurance law is based upon contract law. If the patient, employer has met the contract requirements for coverage such as payment of premium then the insurance business is obligated to perform it’s contractual obligations within a scope of reasonableness. The contract is based upon law, not upon internal rulings within the insurance business by employees not versed in interpretation of contract law. Usually routine templates are taught to the insurance examiner as template for denials of coverage but those templates are not legally enforceable.