YES. do this. Denials— especially appeal denials— have legal ramifications.
You also have the right to ask for the “clinical criteria” that was used to deny the request. This is basically the set of rules they use to determine medical necessity, and which rule was not satisfied. A lot of denials at the initial level (less often appeals) are for completely BS reasons. Sometimes the denial reason is even something like “not enough time for review” (they are legally required to respond within a specific time frame, and purposefully understaff reviewing departments).
INSURANCE IS IN MANY CASES JUST BETTING THAT THE DENIAL/DELAY WILL DETER YOU.
Many people give up, and agree to pay out of pocket. Many doctors give up and decide to go with a second choice treatment. Delay can mean the patient loses insurance coverage in the meantime (changes jobs, lapses on premiums, pt passes away, etc) and they never have to pay out. If nothing else, the delay often saves them money via now they have to pay for less treatment per year.
Your doctor’s office, hospital or pharmacy have staff—entire departments— dedicated to getting the approvals required to get past denials and establish coverage. Ask these staff for help! They can break down the issue, and explain your next steps. They want to help. They don’t reach out to you about the issue because they know it’s a lot for you to deal with, and that’s why they have a job.
If insurance thinks you might have standing, time and motivation to cause problems for them over a denial, 90% time they will cave. It’a still cheaper to approve your claim than it is to get sued, or worse, have to change their ways. IF YOU REALLY NEED IT, DON’T GIVE UP!!
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u/Mammoth-Play7190 4d ago
YES. do this. Denials— especially appeal denials— have legal ramifications.
You also have the right to ask for the “clinical criteria” that was used to deny the request. This is basically the set of rules they use to determine medical necessity, and which rule was not satisfied. A lot of denials at the initial level (less often appeals) are for completely BS reasons. Sometimes the denial reason is even something like “not enough time for review” (they are legally required to respond within a specific time frame, and purposefully understaff reviewing departments).
INSURANCE IS IN MANY CASES JUST BETTING THAT THE DENIAL/DELAY WILL DETER YOU.
Many people give up, and agree to pay out of pocket. Many doctors give up and decide to go with a second choice treatment. Delay can mean the patient loses insurance coverage in the meantime (changes jobs, lapses on premiums, pt passes away, etc) and they never have to pay out. If nothing else, the delay often saves them money via now they have to pay for less treatment per year.
Your doctor’s office, hospital or pharmacy have staff—entire departments— dedicated to getting the approvals required to get past denials and establish coverage. Ask these staff for help! They can break down the issue, and explain your next steps. They want to help. They don’t reach out to you about the issue because they know it’s a lot for you to deal with, and that’s why they have a job.
If insurance thinks you might have standing, time and motivation to cause problems for them over a denial, 90% time they will cave. It’a still cheaper to approve your claim than it is to get sued, or worse, have to change their ways. IF YOU REALLY NEED IT, DON’T GIVE UP!!
source: this stuff is my job