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The Insurance Appeal Process
Appealing a Denied Prior Authorization
Insurance coverage denial can be upsetting, but don’t be discouraged. Unfortunately, many people face this challenge when getting approved for bariatric surgery. It’s important to know that you can appeal this decision and let your voice be heard.
Understanding the appeal process before you submit your appeal is essential. It’s also important that you construct your appeal carefully, making sure that you provide support for each reason you were denied. Typically, your surgeon’s office will submit the necessary information to appeal your denial. If they do not, you can appeal it on your own. How you appeal your denial depends on the type of plan you have (fully-insured or self-insured).
If You Have a Fully-insured Policy
The next step is to resubmit the authorization. For the re-submission process, you’ll need to know why you were denied. Don’t be afraid to call your contact and ask for a detailed explanation in writing as to why you were denied.
Once you receive the explanation, read it carefully. Most times, denials are categorized as either “Not Medically Necessary,” “Experimental Procedure” or “Excluded Procedure.” If there is something in it you do not understand, call your provider and ask for a more detailed explanation.
“Not Medically Necessary” Categorization
In the event the denial was categorized as “Not Medically Necessary,” talk to your provider to ensure the correct codes were used and then request a letter from your doctor stating the nature of the procedure. Once you have the correct codes and a letter from your doctor, resubmit (Please click here for a sample letter).
“Experimental Procedure” Categorization
In the event the denial was categorized as an “Experimental Procedure,” talk to your provider to ensure the correct codes were used and then request a letter from your doctor stating the procedure is not experimental. Once you have the correct codes and a letter from your doctor, resubmit (Please click here for a sample letter).
“Excluded Procedure” Categorization
In the event the denial was categorized as an “Excluded Procedure,” once again, talk to your provider to ensure the correct codes were used. At this point, make sure all factors of your severe obesity status have been reported, such as any related or “co-morbid” health conditions that affect you (heart disease, diabetes, sleep apnea, etc.). Once you have the correct codes and a letter from your doctor stating your current health condition (including all co-morbid health conditions), resubmit (Please click here for a sample letter).
Some insurance providers are limited by the state in which they operate as to the number of appeals they can accept from patients. If you’ve reached the maximum number of appeals from your insurance provider, you may be eligible for an external review. Check your Explanation of Benefits (EOB), or the final denial of internal appeal you received from your insurance provider for details on how your plan handles external review, including the timeframe in which an external review must be formally requested. In many cases a written request for external review needs to be filed within 60 days of the date the insurance provider sent a final decision.
If You Have an Employer’s Self-insured Medical Benefits Plan
The denial probably will occur at the predetermination stage of the process; therefore, you may not receive a formal Explanation of Benefit (EOB) form from the provider denying the authorization. In order to submit an appeal, you must receive a formal written denial, usually in the form of an EOB. This EOB should include a paragraph explaining your appeal rights and how to submit an appeal. Such as:
If you do not agree with this determination, you may appeal it in writing to the Pension and Benefits Appeals Board within 60 days of receiving this letter. In addition, you have the right to appear personally before the Board, review pertinent documents, submit issues and arguments in writing, have a representative appear before the Board or present written issues and arguments, and present additional information to the Board.
The denial should also give you a detailed explanation why you were denied, and what specific sections of the plan were used to make the denial.
Don’t be afraid to contact the provider to request the details of your denial. Also, if you’ve studied your plan and feel there’s a specific portion of the plan that allows for the treatment, you should ask them to review your denial with this in mind. It’s possible an insurance company has applied the rules they have for their insured products, and not the plan rules for the specific employer, when making initial determinations.
The laws and regulations that allow a company to get tax advantages for providing employees with medical benefits also require the plan to implement an appeal process. A verbal denial does not meet these regulations. If you cannot get a formal denial from the provider, contact your employer’s personnel or benefit department for a formal denial. At the least, the plan must respond to your claim within 60 days or they may not be in compliance with ERISA.
Once you’ve received the denial, you should submit your appeal paying close attention to any time limits required by the process. This may sound like a lot of work, but in the end the benefits to your health are worth the effort.
The process of contacting and working with your insurance provider may be a frustrating one. Do not become discouraged. By taking your time with each step and maintaining patience, you will only enhance your ability to have your treatment option covered by your insurance. Remember your rights as a policy holder, and do not be afraid to ask questions.
Statistics to Include in Your Appeal Letter
These statistics briefly detail severe obesity and its affects in the United States. Feel free to use these statistics when writing your letter(s) to your insurance provider. Educate them on the economic benefits of covering bariatric surgery, as well as the effects this disease has not only on you and your quality of life, but also on others.
- It is estimated that 7.7% of all Americans have severe obesity. Severe obesity is characterized by an individual weighing more than 100 pounds over their ideal body weight, or having a body mass index (BMI) of 40 or higher.
- Approximately 75 percent of people with severe obesity have at least one co-morbid condition (diabetes, hypertension, sleep apnea, etc.) which significantly increases the risk of premature death.
- The life expectancy for a 20-year-old male with severe obesity is 13 years shorter than a male of the same age who is not obese.
- Annual direct medical expenditures attributable to obesity are $147 billion.
- Downstream savings associated with bariatric surgery are estimated to offset the costs in 2 years (laparoscopic procedure) to 4 years (open procedure).
- Post-surgery drug costs for diabetic and anti-hypertensive medications decrease dramatically. Potteiger study found a 77.3% savings.
This content is adapted from The OAC (Obesity Action Coalition) Insurance Guide.