Your Insurance Denial Battleplan

Helping individuals fight their insurance companies to obtain the devices that are both necessary and entitled policy benefits has become a professional highlight. Over the past decade, rubber stamp denials have become the industry norm. I suppose that these multi-million dollar companies are hedging their bets that people will become lost in the sea of red tape and eventually give up pursuing their benefits. Enough people must accept the denial to make the process profitable for the insurance company, otherwise claims would have always had a fair review upfront. 

Declaring a device or component "Not Medically Necessary" is one of the hallmark rubber stamps used by insurers. This often blanket verdict is baffling for the patient and cumbersome for the practitioner to fight. Although it shouldn't be this way, far too often the patient is left to fight for the device with little or no support from the provider.  Ideally the prosthetist would take the lead during the appeal process, but the emails I receive from frustrated patients tells a different story.

Dave, my podcast partner, and I have been talking for years about providing a guide for individuals to fight their insurance denials. We have wanted to map out the method that we have both successfully utilized to overturn denials during the appeal process. In full disclosure, I can lay no claim to the method. I learned it from Dave during a seminar and have applied it (with success) through the years.

In last week's podcast, we finally walked through the process to fighting an insurance denial on the basis of medical necessity. We have provided a clear method to drafting an appeal with the greatest likelihood of overturning the denial. While nothing is 100%, we believe that following the steps that we have outlined and explained provides the best chances for a positive outcome.

I always feel more comfortable writing something after reading an example. With this in mind, we have created and included a full appeal on our website. It is our hopes that, by using the steps we outlined in our podcast and after reading the example, patients will have a better chance at obtaining the devices that they so desperately need.  If you have any questions, please don't hesitate to reach out to us either through this blog or ampdpod@gmail.com. 

Pup Rescue

Although it started out mundane, yesterday morning quickly became action packed and is sure to be one I won't forget. On my way home from dropping off Robby at school I saw plumes of black smoke billowing so strongly that I knew the source was nearby. Intrigued and worried, I turned down the road to investigate. My heart stopped when I saw flames starting to whip out of the back windows of a house that was situated down a small hill from the edge of the cul-de-sac.

Shaking and with my heart racing, I nervously dialed 911. I stammered over the street name and was unsure of the house number, but I assured the dispatcher that the house would be easy to locate because it was gray and it was on fire. (Apparently I become a tinge of a smart ass when I am panicked.) As I was hanging up the call I noticed movement in the backyard of the house that was ablaze. I immediately knew that it was a dog.

Thankfully the flames, although still flickering out of the windows, were not encroaching on the yard. I managed to grab the cantankerous dachshund as the fire trucks began to arrive. A neighbor met me at the front of the house and agreed to hold onto the puppy until the owner arrived home. I gave her my phone number and name should it be necessary for insurance claims or an investigation before schlepping back up the hill to my car. Timmy was still playing with his little train in the backseat, completely unimpressed with the scene that just unfolded. 

It took awhile for my heart to calm down after returning home. Fires are scary and are not something you want to encounter! After the adventure of the morning, I was happy to spend the rest of the afternoon with my convalescing little Hamlet.

Silly Insurance Issue!

I feel like I spent yesterday with the phone glued to my ear and spinning my wheels. My day was packed with conference calls and a cranky sick toddler. Little Hamlet was feeling horrible, and there was little I could do to make him comfortable. Even though I could manage the calls while caring for him, I felt guilty for not being able to disconnect from the world to cuddle with him for a few hours. Mom guilt will haunt me regardless of the situation.

My greatest accomplishment was finally being able to convince our health insurance company that Robby's ear surgery was not required because of a work-related injury. I'd say that I was surprised that it took me 45 minutes to explain to the insurance adjuster that my 10 year old son did not have a workman's compensation claim pending because of his congenital ear issues, but nothing really shocks me when it comes to insurance companies. The fact that I had to expend my energies on the issue was absurd. 

By the time Scott came home with Timmy's new medicine in hand, I was emotionally and physically spent. The small ingrown hair on my stump had grown into a large boil throughout the course of the day, adding to the misery of the day. All I wanted to do was to take off my leg, curl into bed and cry. Mom guilt and leg pain are never a constructive combination!

I'm hoping that Timmy is feeling better today, but I am fairly certain that won't be the reality. As frustrating as this is for me, I realize that it is at least ten times harder for him. At the very least I hope that his new meds begin to work and that my little guy returns to his mischievous self soon. I miss my little troublemaker. Of course, a day curled up on the couch may be the perfect medicine for us both.

Laid Back President's Day

Just as predicted, and exactly as needed, our President's Day was low-key.  Timmy quietly played with his trains, watched cartoons and occasionally brought me a book to read.  Robby enjoyed the day chatting with friends on the computer and playing a variety of video games.  After taking a load of old furniture outside to await for the junk removal company, Scott watched television and relaxed for the rest of the day.

Today Robby and Scott will return to school while Timmy and I continue convalescing at home. I'm hoping to invest a lot of time tidying up our downstairs family room. Now that the extra bed mattresses and couches have been removed, I have a relatively clean slate. My goal is to create a fun playroom for Timmy. I know that I won't get it all done today, but I'm hoping to take a chunk out of the project.

If the weather stays warm we might go outside to play, although right now I'm protective about giving his little immune system a break. I am not going to risk his becoming ill again!  Hopefully he won't become bored with our newly imposed quarantine. In the end, I know that he just needs time to get stronger and healthier. ;

Exile

After another weekend away, it is nice to be home again. Although this trip was short, I think Timmy is the most relieved to be home. As soon as arrived he began exploring all of his toys to make sure that nothing was missing. He then grabbed puppy blanket and cuddled up on the rocker next to me to watch cartoons. He seemed content to be laid down in his crib when it was time for bed,  his little pink cheeked face reminding me that he isn't feeling well.

We've been doing a lot of traveling lately, but the next few weeks we have nothing scheduled.  We aren't going to have any grand adventures or getaways. Instead, I plan on staying home and focus on getting Timmy stronger. My sweet little Hamlet has been sick or recovering from an illness for months. We (Timmy and me) won't be going anywhere in public until he is better.

Today is President's Day, which means that Scott and Robby are home from school. I have no plans to fill their schedules with tasks and chores. Instead I'm going to lay off and just let everybody relax. After all of the commotion recently, I think we all need some time to decompress and relax.