The insurance appeals process - take note!

So yesterday I called Anthem to check on my appeal of the denial of Eric’s pump coverage. I guess I didn’t put anything in about this, but the deal is, on October 7 his endo sent a letter to Anthem detailing that Eric’s pump is medically necessary. Having had no acknowledgment of this letter in the past 3 weeks, I called them to check on it. Was told that the letter hadn’t been sent to the Appeals Department because a specific one-page form that is supposed to accompany such letters (of which no mention was made in the description of the appeals process) was not submitted by my endo. In other words, they got the letter and filed it and didn’t put in an appeal, because the form they didn’t tell us was needed wasn’t submitted. Grrrr.

As it turned out, my call was all that was required to start the appeals process… sort of. It got the letter sent to the Appeals Department, and it got me the name of the person in the Appeals Department to whom this stuff needs to be sent. I was then informed that Anthem would still need the documentation that was originally submitted to Medtronic. So I had my endocrinologist fax those documents over to the woman at Anthem. And I had them send the same documents to me. I will follow up next week to make sure that they have all they need to start the appeals process, and if they don’t, I will take my endocrinologist’s letter and documentation and personally deliver them to the Anthem office in South Portland.

The moral of the story:

Call your insurer and ask them exactly what they need to start an appeal, and ask if there are any specific forms to be submitted (there will be). Get those forms. Fill them out personally if you can, and if you can’t, take them to your endocrinologist, have the endo fill them out. Then make a copy for your files. Then send them by registered mail, Fed Ex, or take them in person to your insurer’s office. Then follow up a week later with a phone call to be sure the process is under way.

Is it a hassle? ABSOLUTELY. But the insurance companies make it deliberately difficult to discourage appeals. Even the freaking phone tree at Anthem is convoluted! I screwed up the button pushing twice before I finally gave up and tried the “hit zero a zillion times” method (it worked).

My mom worked answering phones for a major health insurance company for 8 years and says the same thing. The reason denials work so splendidly for insurers is that people don’t go to the trouble of appealing because they assume it’s a lost cause. If you’re tenacious, your appeal can (and often will) be accepted.

She also says that one time when her supervisor was about to be audited regarding the number of cases pending appeal, she caught him throwing away four filing cabinets full of appeals into the dumpster out back. It has always haunted her how many people those papers represented who never knew why their cases ended up lost or denied.

It’s worth the hassle to try again and again.

Do you mind if I use this wording in my book? “The reason denials work so splendidly for insurers is that people don’t go to the trouble of appealing because they assume it’s a lost cause. If you’re tenacious, your appeal can (and often will) be accepted.”

I don’t think I could phrase it any better…

Sure, Elizabeth.

I was with Anthem from 07/2008 through 07/2009 and went through a denial/appeal/approval to get my Navigator CGMS. The initial denial was based on a lack of timely paperwork, even though my CDE had sent it THREE times between July and October. My appeal process was to actually call the extension of the woman who denied it (my nurse had come up with the phone number). This woman was not pleased that I was calling her directly, but within 15 minutes, I had convinced her that I met the requirements for the device and she gave me a ten-digit pre-auth code to give to Abbott and the DME supplier to get the device shipped. I had my CGMS in hand by November 4.

aftet dealing with workers comp (aka gov run insurance co–well it was–now it is quasi gov run) and Social Security (gov run ins) for 20 + years due to my husbands on-the-job injury–the horror sotries make pump and CGMS denials pale—but the end story is the same. Insurance companies make it as hard as they can to make you give up.

Learn your policy. Keep a log–names dates and times of everyone you talk to, everything you mial and the cert#'s and return receipt stubs. Keep fax confimraitons and mail everything certified mail that is important. When doing so make sure each piece of paper that you encolse in the certified mail has the certified mail # on it–this is an important step.

Don’t give up…the more times you appeal–the less daunting itis and the less they mess with you.

Find out ahead of time how your state insurance commission/governance works, how to report the insurance companies to them for harrassment and non-compliance–and then do it. At the very least normally the larger the # of complaints the more it hurts the insurance companies bond rating…some states even fine insurance companies for doing wrong and give the $$ less the admin fee to the insuree. Most people never bother to check–it is a pain…but if more people did it it would help cure the deny everything first policy of most insurance companies.

Insurance companies want to see if you’ll jump through all their hoops to get what you want. I’m glad you stuck with it and kept bugging them. I swear they brainstorm to figure out ways to irritate their subscribers.

Glad to see that you were able to get the ball moving with the insurance company. They will sit on documents until you call. It has happened to me multiple times. I would call them every single day until it is resolved, because things will just sit there. Just by pure numbers you will finally reach a customer service rep that has a huge heart and loves their job and will sit on the phone with you until proper steps are taken.