Getting A "YES" From Your Insurance Company
Once you've determined that you or some one else with a disability needs technology, you must decide how to get it funded. Families with health insurance need to look at their policy to decide if it will fund the device. Insurance benefits vary widely from policy to policy. Just because your friend tried to get a device funded through his/her insurance and they denied it, doesn't necessarily mean your insurance would do the same.
Get to Know Your Plan
Reading your insurance policy, especially the explanation of benefits, is extremely important. If you don't have a copy of your policy, it is your right to have one. Call your insurance company right now! It contains good information about how to file a claim, rental coverage of equipment, and how to file an appeal.
An insurance policy is a contract between the company and the insured. If it's listed in the policy, they cover it. If they do not mention it, they do not cover it. As with most contracts there are gray areas. Fortunately, for the insured, that means the policy is open to interpretation. If the insured person can make a strong argument that it is a covered service, then the company must prove it isn't.
As you read the policy, try to answer these three questions.
What does it cover?
First, you will need to find your policy's definition of medical necessity. It's usually listed near the beginning of the summary of benefits. The definition of medical necessity forms the foundation for determining if a claim is valid. Remember that your policy covers medical claims only. So, the definition of medical necessity is the first hurdle you need to clear. Below is just one example of a definition of medical necessity in a particular policy.
Medically Necessary: Means the treatment, confinement or services prescribed by a Physician that is not of an experimental or investigative nature. The Trustees may rely on the advice of a medical professional retained by the Fund to determine whether a particular service, supply or procedure is medically necessary. The Trustees are the sole and final judges of medical necessity for benefits payable under this plan.
The example offers a liberal definition of medical necessity. It generally says that anything but experimental treatment is covered if a physician orders it. Other policies have more restrictive definitions. You need to find out the exact language in your policy.
Next you'll need to figure out where they cover medical technology in your policy. You probably won't find the words medical technology in the summary of benefits. More than likely, you will find the benefit listed under one of these terms: durable medical equipment, prosthetic device or speech, physical or occupational therapy. Find out the definition of each service listed in the policy. For example, say you want your policy to cover an augmentative communication device (an electronic device that can 'speak' for a person who is unable to communicate verbally).
Nowhere in the policy is augmentative communication mentioned. However, as you review the policy you find that the definition of a prosthetic device includes the line: A device used to replace or support a missing or non-functioning body part. That certainly describes augmentative communication. You could use that portion of the policy as a rationale to get the device covered. The communication device meets the prosthetic definition within the policy and your insurance company may cover it.
What doesn't it cover?
Insurance policies usually have a section that describes items that, may be medical in nature, but, the policy does not cover. That area is usually called exclusions. Be sure to read that section to see if they specifically exclude the device you need. For example, many insurance plans exclude orthodontia and experimental surgery.
Does that mean the company would never cover those services? It seems the answer is yes, but it's not necessarily so. Below is one parent's example of how she got orthodontia covered when there was a specific exclusion in the policy.
My daughter was inarticulate until she was eight. Nevertheless, she did develop speech skills at that age and continued to improve her articulation until she reached the age of 12 when things started sliding downhill again.
We got the diagnosis after evaluations by her pediatrician, pediatric otolaryngologist, dentist and orthodontist. She simply ran out of room in her mouth to articulate speech. She had a vaulted palate, teeth that were far from straight (from anti-seizure medication), causing even less room and finally her 12 yr. molars arrived on the scene. There was no room for her tongue to move around. The team recommended orthodontia.
Our insurance policy had a specific exclusion for orthodontics. However, as I reviewed our policy, I felt like the claim related to speech therapy (a covered service) more than orthodontia. Because, if she didn't have the medical treatment, she would continue to lose speech skills. So, I filed a claim under major medical (speech therapy) to have the orthodontia covered.
I received a denial. Nevertheless, I filed an appeal and won. The insurance company paid 80% of the claim despite the fact they had listed orthodontia as a specific exclusion to the policy.
So, as you can see, even if there is a specific exclusion in your policy it doesn't necessarily mean that you can't get it funded. It means you need to find the right justification within the policy to get it funded. Still, you need to know what your policy states about exclusions.
What specific language does the policy use?
The policy will use specific language about covered services. That language directly relates your benefits as a policyholder. Get to know that language. If you fashion your request in a way that uses the language of the policy to make your points, it reduces the likelihood of confusion about your claim.
If you think a communication device fits the definition of prosthetic best, then in your claim call it voice prosthesis. That way the company will better understand your claim and where it is covered in your policy.
Overall, it's a good idea to jot down important information and list page numbers so you can easily retrieve the information. Once you've read the policy, go back through your notes and reread the sections you felt were important. For example, if you need a wheelchair funded, you probably would highlight the section on Durable Medical Equipment (DME). You may also want to highlight the rental section, if you have a short term condition. If you need to get a leg brace funded, you may highlight the sections on prosthetics or physical therapy. If you need to get an augmentative communication device funded, you might highlight sections on DME, prosthetics and/or speech therapy.
Once you figure out where your medical technology fits best under the benefit plan, you are ready to gather all the pertinent information. This is usually called creating the justification.
Insurance companies will only pay for items that are medically necessary. If they feel an item is educational in nature or consider it a luxury item, they will deny the claim right off the bat. That is why it is important to medically justify your medical technology need.
You will first need a letter of medical necessity from your physician. The letter should include information about your disability and its affect on your physical and/or cognitive abilities. For example, you need a walker to get to the bathroom without falling. The walker addresses your, safety, hygiene and hydration needs. They re medical needs. Being mobile is not necessarily medical. If you need an augmentative communication device an appropriate medical justification may be to express health needs. You will need it to tell your caretaker that you are sick, or that the bath water is too hot, or that you are hungry. Your physician will also need to write a prescription for the medical technology.
Next, include any evaluations or assessments that recommend the need for the device. These evaluations usually come from a speech, physical or occupational therapist, or some type of rehab specialist. The justification should address the following areas.
How long the evaluator has known you? If you went to see a therapist specifically for the evaluation, it's OK to say so. However, if the evaluator does not know you well you may want to strengthen your claim. You can do that by getting a letter from a therapist who knows you better stating they agree with the evaluator.
A definition of your condition. The justification must specifically address your disability or condition. It should contain specific information about your disability or condition.
Document adverse impact on "normal' functioning. It's important to prove that because of the disability or condition you have deficits. If you can't prove it, there is no reason for the company to approve the claim.
Prove why the device is treatment for the disability or condition. Why is this device medical? This is where the therapist creates the link between the device and its medical purpose for you. In addition, it shows the insurance company that it is a benefit of your policy. This is a crucial step in the process. By not addressing this issue, you guarantee a denial.
An explanation that the treatment (device) will lessen the disabling effects of the condition. This too, is an important part of the justification. After all, if the device doesn't help meet your medical need, why should they pay for it? For example, say you need a communication device for vocalization. The therapist could explain how the device assists you in expressing your physical and mental health concerns to health care professionals and care givers.
Prove that it is the least costly treatment alternative to achieve the result. Insurance companies usually don't mind providing services covered in their policies. However, they don't want to buy a Cadillac when a good Chevy would do the trick. The justification needs to address the fact that the therapist looked at several devices and ruled out some because they were inappropriate, or too expensive and a less costly device would do the same job.
These evaluation reports usually include devices tried and why one device is more appropriate than another. It will describe how the technology is going to help maintain or improve health. This proves its effectiveness versus cost of a device.
Families can also provide documentation to convince the company about the medical need for the device. You can write your own justification letter. It can include information on every day, real-life happenings.
You can also gather information about the device: a picture, a brochure, price lists, etc. Many vendors have success stories of others who used the same device. Keep in mind that the information should relate to medical need. For example, a story about how a child uses an augmentative communication device at school, demonstrates an educational rather than medical intervention.
Consider videotaping the user trying to perform a medical function with and without the device. It dramatically proves how necessary the device is to the user. You can also send a photograph with the claim. It can remind the claims adjuster there is a person behind all the paper.
Once you gather all the documentation it's time to submit the claim. Most insurance companies require completing a major medical form. If you don't have one, you can get it from the company or from the group's administrator at work. Make copies of all the documentation and attach it to your claim form. Keep a copy for your own files just in case your claim gets lost! Now it's just a waiting game.
Finding help along the way. Often policy holders want to find out how the claim is moving, or they may experience problems getting that 'yes.' Usually, they call the insurance company and get forwarded to the claims adjuster for help. If possible, try not to deal with them. They may not be your best advocate in this system.
Think about who in the system wants to make and keep you (or perhaps your employer) happy. It is the sales agent. He/she gets money for every person who holds a policy. It is in his/her best interest to keep you happy. If you have a question about coverage or the progress of your claim, try contacting your sales agent for information.
If you get a letter denying your claim, you do have a right to appeal the decision. Don't let a 'no' discourage you from trying again. That first 'no' is very often a gate-keeping function to see if you will go away. Persistence pays. The squeaky wheel gets the grease. If at first you don't succeed . . . you get the idea, don't you?
Your policy should contain a section on appeals. It differs from policy to policy, so get to know exactly what your policy requires. Carefully follow the steps outlined in your explanation of benefits plan.
If you use all the internal appeal procedures and are not successful, all is not lost. You can still appeal to the Illinois Department of Insurance. Follow these steps.
Write to: Illinois Department of Insurance, Consumer Services, 320 West Washington, Springfield, IL 62727
In a letter, briefly explain the complaint. Send documentation to back up the complaint. The department will investigate your complaint and get back to you.
Most denied claims occur because the person submitting the claim forgot to sign the claim form. That delays the process and adds to the policy holders frustration. Be sure to follow all the procedures listed in the policy and double check your work to make sure it is all there.
Paint a complete picture.
Claims adjusters can only make decisions based on the information you give them. Make sure they have everything they need to get that 'yes.' For example: You need an electronic lift to help you transfer from the bed to your chair. You need an electronic one because you live alone. However, you didn't tell the company you live alone. They could deny your claim because they felt a hydraulic lift would work for you, not knowing that the reason you ruled out the hydraulic one is that it requires someone to operate it.
Self Insured Organizations.
If a self-insured organization insures you, you still should have appeal procedures. However, if you exhaust the internal procedures, you do not have the right to go to the Illinois Department of Insurance. They do not have jurisdiction over self-insured plans.
Remember: READ, JUSTIFY, FILE