If you have been denied by your insurance company for the Second-Level Internal of Appeals, you’ve now exhausted all of your internal appeals rights. The last step in the process is to submit an external review with your state’s Department of Insurance (DOI)

After all the work you’ve completed so far, it can be extremely discouraging knowing that you have no more rights within your insurance company to fight for the requested DME you, and your medical providers have tried to justify is “medically necessary” for your disability.

Don’t lose hope yet though as you have one more shot with your external review in addition to going above and beyond reaching out to your local legislators and local media.

External Review Process Steps

There are two steps in the external review process:

  1. You, the patient, or an appointed representative such as a doctor or other medical professional files an external review.
    1. You must file a written request or submit by email for an external review within four months after the date you received a notice of final determination from your insurer that your claim has been denied.
  2. External reviewer issues a final decision.
    1. An external review either upholds your insurer’s decision or decides in your favor.  Your insurer is required by law to accept the external reviewer’s decision.

The DOI consists of a panel of independent reviewers who are supposed to have a specialty in the area of your disability.

When filing an external review you can also request an expedited review if requested DME is urgent for in-home care.

External Review Types of Denials

  1. Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan.
  2. Any denial that involves a determination that a treatment is experimental or investigational.
  3. Cancellation of coverage based on the insurer’s claim that you gave false or incomplete information when you apply for coverage.

How Does the External Review Process Work?

Parties involved for External Review:

  1. Patient or representative patient is appointed to submit paperwork such as a medical professional. It’s advised that patients submit all paperwork to ensure all paperwork is submitted correctly.

External Review Flow

  1. Patients need to find their state Department of Insurance (DOI) website to submit an external review online or download paperwork to send in.
    1. Scroll down on website to section “How to contact your state insurance department.” https://www.nerdwallet.com/blog/insurance/how-state-department-insurance-can-help/
  2. Each DOI website looks similar nature, so follow these steps:




  1. Patient or medical representative to submit the following information:
    1. All previous denials from health insurance provider
    2. Copy of insurance card
    3. All pertinent medical records from your medical professionals
    4. Personal patient letters written to insurance company
    5. PT LOMN/Evaluation & addendum
    6. PCP LOMN & addendum
    7. Any further information you think might help your case such as photographs of requested DME and how it helps you in your home, writing an extra letter pleading your case as a patient, etc.

NOTE:

Since this is your last chance to plead your case for requested DME it is best to throw in the kitchen sink and then some. (i.e. photographs of how requested DME improves your life within your home, further letters explaining why requested DME is so crucial to your daily life, improves your assisted daily living activities, and makes you more independent.

Timeline Expectations

Patient Recommended Responsibilities

Patient responsibilities during an external review are a bit more cumbersome during this stage of the process because while you can have a medical professional submit documentation on your behalf, it’s really in your best interest to submit all documentation online or send in by mail yourself.

The reason being is you want to collect all of your:

  • Denial letters from your insurance company
  • Letters of Medical Necessity from your Medical Professionals & Physical Therapists
  • Potential Clinical data on requested DME
  • Personal Patient letters written by yourself

This can be a lot of paperwork to send in, but throughout the entire insurance process you want to make sure to have a physical folder with all of the documentation or stored somewhere on line as you go.

Also, since you have multiple medical professionals who will be involved in the process it’s highly doubtful they will have all of your documentation in one location and send in everything in its entirety.

During each phase of the denial process it’s best to create a folder titled, for example, “Prior-Authorization,” or “First-Level of Appeals.” This way you have all of your paperwork organized, and it won’t seem as daunting when you have to submit it to the Department of Insurance for an External Review.

However, you only get one shot at this so you want the Department of Insurance to not only have all of the facts, but plead your case further so they can overturn your insurance company’s final denial decision.

You are really in the driver seat on this one, so be organized, stay upbeat because by this stage of the game you likely have been through quite a lot, are exhausted, frustrated, but don’t give up yet!

Tips & Tricks #1: Patient Tips

  • This is your last official chance to have your insurance denial overturned by the Department of Insurance. With that said, it is in your best interest to gather as much information and add any addendum you can when submitting your External Review.
    • For example, take photographs, write personal letters, attached clinical papers if applicable, etc.
      • The above is all extra paperwork you will want to submit in addition to all of your Letters of Medical Necessity, denial paperwork from your insurance company, etc.
  • As mentioned in the Patient Responsibility Section, you can definitely have a representative submit all of this information for you, but it’s in your best interest to take control, and submit the application yourself.
    • This will allow you to make sure you have all of the right paperwork.

Next Steps If You Are Denied Your External Review

If you are given a final denial by the Department of Insurance the disappointment level can definitely be high. It may appear as if you have exhausted all of your rights, but as mentioned in previous steps above, you still have a few cards to play.

The three main avenues you have at your disposal are:

  1. Reaching out to your Local Elected Officials
  2. Reaching out to your Local Media
  3. Hiring a Lawyer
    1. Most people don’t have the funds to hire a lawyer. Most states have a disability rights organization that have pro bono healthcare lawyers on staff. They may not always be able to take your case, but it’s worth reaching out to them to see if they have any suggestions or options for you.

Lastly, even if you are denied a piece of equipment that you and your medical professionals think is medically necessary, but your insurance company disagrees with you … You are taking the first step to change the system.

It all comes down to a great number of people getting together to change policy. Many people may not be up for this, which is fine, but if you are one of those who want to take things a step further to make systemic changes in the healthcare system – it always starts with one person.

Rome was not built in a day as they say. With respect to medically necessary equipment, ponder this for a moment:

Many years ago the tilt function on a power wheelchair was not considered medically necessary for the severely disabled. After many thousands of disabled folks, lawyers, physical therapists, and other advocates in the community put a great deal of money into clinically proving that weight shifting back in your wheelchair prevents pressure sores, thus reducing long-term healthcare costs for insurance companies – Medicare, where most policy shifts start, deemed the tilt function on power wheelchairs is medically necessary.

Change has to start somewhere, and if you are really interested in advocacy, just keep going by any means necessary whether that be working with your elected officials, creating social media campaigns to change the system, or working with your local media outlets.

Reach Out to Elected Officials

While you are waiting for a decision from the Department of Insurance on your case it is a good idea to familiarize yourself with all of your Federal, State, and Local Legislators.

If you are denied by the Department of Insurance, the next step of the game is to reach out to your Elected officials to see if they can help you, and if you have a case to find a loophole within your insurance policy or whether or not your final insurance decision was just for your medical situation.

If you have all of this information prepared, then if you are denied, you can start taking action right away, and have the right people in your corner to help you.

Click here to find your Elected officials.

Tips & Tricks #2: Elected Officials Tips

  • You may have to cycle through multiple offices within your federal, state, and county representatives before you find the right person to speak with.
  • You may have to leave multiple messages, put reminders in your calendars to follow back up if you have not heard back from someone in 2 to 3 days, and be persistent in your efforts.
  • Every time you speak with someone in an elected officials office take notes with respect to whom you spoke with, their contact information, and advice they gave you.
  • Many elected officials offices have a Constituent Complaint Form, which you can fill out and will get directed to the appropriate person who you need to work with. Make sure to ask for this!
  • It’s very likely that you may speak with certain people in different offices who say they cannot help you, but if you keep calling different people there will likely be someone who can at least point you in the right direction.

Most importantly, don’t give up!

Reach Out to Local Media

After you have exhausted all of your internal level of appeals with your insurance company and while you’re waiting for your Department of Insurance external review it’s a great idea to start gathering a contact list of your local media investigative reporters.

Insurance companies generally do not like negative publicity and if you have a real case, and even if the Department of Insurance denies your claim, oftentimes having your story put out there in the local media has an interesting way of changing an insurance company’s final decision.

This process can seem a little bit daunting, but the best way to go about it is to:

  • Google your local media stations
  • Call the news desk and pitch your story in combination with;
  • Looking up your local investigative reporters and writing them emails personally with your story. Make sure to write a very personal story about why you were denied, why the piece of DME equipment is critical to your survival or medical necessity in your home, and show them that your quality of life has been diminished.

Tips & Tricks #3: Local Media Tips

The biggest piece of advice we can offer you is to be pleasantly persistent and aggressive when reaching out to your local media because there are always dozens of stories each day they have to choose between.

  • You may have to call multiple times, leave multiple messages, and send multiple emails.
  • Your story may not always get picked up, but you have to be aggressive and persistent because there are so many people around the country who need to have their stories heard.
  • News agencies get flooded with human interest stories all the time. What’s the worst they can do? Say “No, but at least you tried.
  • Try and title your email something along the lines of “disabled person denied medically necessary equipment for survival,” as an example. You have to make the title a little bit more dramatic in order to catch their attention.

 

SPINALpedia

SPINALpedia
Spinal Cord Injury
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Bethesda MD  20814
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