Appealing Insurance Denials

My own fight with appealing insurance

Picture this.

It's the middle of a Covid surge in South Florida, and hospitals and nursing homes are not allowing visitors. I get a call that my grandmother has fallen and broken her hip. She was admitted to a hospital, and underwent successful surgical repair. She got through a few post op complications and was working well with the therapy department.

Once she was medically optimized, I requested for my grandmother to be transferred to my acute rehab. To my horror, her insurance denied acute rehab, citing "medical necessity.” As you might have guessed, I was outraged, especially since her insurance was trying send her to a sub acute rehab, where she would not be allowed any visitors, and also receive less therapy and medical attention.

Click here to read an exact copy of the letter I wrote insurance

I wish I could say she was immediately transferred to my rehab. But sadly, the hospital kicked her to a nursing home before the appeal decision. Three days into her nursing home stay (during which time she received no rehab), the decision was overturned, and she was approved for acute rehab.

My grandmother was uprooted again, and transferred to my rehab. There, she got the care she deserved, and was successfully discharged home. Now, we would like to teach you how to advocate for what is best for you and or your family.

Step by step guide to appeal insurance denials

Try to stay calm and be nice. You will get the best results being friendly. Yes I know it is hard and not fair having to fight in this time of stress but you will need assistance from the hospital staff. Remember you get more bees with honey than with vinegar.

Officially, this is a process in which a physician or other healthcare professional speaks with a representative from an insurance company to discuss the medical necessity and appropriateness of a particular treatment.

In reality, insurances make it very inconvenient for a physician to perform these calls. Having us call in at weird times and then placing us on hold in the middle of a busy work day. I have done these, and they rarely work. In my opinion, the medical reviewer has already made up their mind before the call has begun. The insurance rarely listens and recites vague guidelines for a denial, sounding more and more like a robot each time.

Yet some insurance are more responsive to these peer to peers than others. In my experience, if the patient has insurance in the NaviHealth family ( Preferred Care Partner, United Health) the peer to peer results in automatic NO, with artificial intelligence playing a role.

Here is an examples of a peer to peer call. It's the last five minutes when I am asking the reviewer to explain the reason for the denial, the reviewer can not , gets frustrated and hangs up. The insurance denied the case but the patient was able to successfully appeal the insurance and complete a productive acute rehabilitation stay.

Submit a written appeal to your insurance company, citing the specific reasons why you believe the denial was incorrect, and including any relevant supporting documentation. Here is where I see the most positive results. Now remember the hospital system may scare you into trying to get you to leave using words like you will be stuck with the bill or you will lose a bed at a subacute rehab and so on and so one. It’s the case managers job to get you out of there.

Another issue some physicians have to deal with is the patient length of stay. In some hospital systems physicians are monitored how long a patient is admitted and you guessed the more days the worse it looks for the physician. Just another metric a hospital system to potentially deduct pay from a physician.

Stay calm , be nice and explain you are filing an expedited appeal. You have the right to appeal the insurance decision. Of course insurance doesn’t want you to appeal, makes it seem like a daunting task. When is the last time you had to write an official later? This is a game to the insurance industry team which Team Rehab will win. Don’t be intimidated, you can handle this and we are here to help.

Follow up with your insurance company to confirm receipt of your appeal and to check on the status of the review process. Keep records, not only include a copy of what you sent, but also when you sent it and when it reached the insurance payer, any who you have talked to. The hospital may need to send in updated clinical notes the case manager or rehab coordinator should be able to assist.

Your hospital case manager submits an INITIAL INSURANCE AUTHORIZATION.

If the authorization is denied...

PEER-TO-PEER REVIEW

Request the hospital to initiate a peer-to-peer review. Your current doctor at the facility and a doctor at the insurance company may discuss if the insurance company can agree to approve the stay (process takes approximately two days).

PEER-TO-PEER APPROVED?

YES

NO

The rehabilitation facility liaison will help firm up the plan and move ahead to admission.

If the peer-to-peer review request is denied, there is an option to submit a FAMILY OR EXPEDITED APPEAL (process can take 3 to 10 days to complete).

Follow up with your insurance company to confirm receipt of your appeal and to check on the status of the review process. Keep records, not only include a copy of what you sent, but also when you sent it and when it reached the insurance payer, any who you have talked to. The hospital may need to send in updated clinical notes the case manager or rehab coordinator should be able to assist.

How to format appeal letters

The header of the letter will vary by insurance.

It should include most of the following information:

Attention: Expedited Appeal
Reference #
[ Date ]
Re: [ Name of Person Whose Claim Was Denied ]
Insurance ID: [ Enter the insurance ID # for the person whose claim was denied ]
Date of Birth: [ Enter the birth date for the person whose claim was denied ]
Claim Number/Case ID : [ Provided by the Insurance ]

Real life examples of letters written for my patients that have successfully overturned an insurance denial for acute inpatient rehabilitation.

As you can see in this example the letters are repetitive, short, and to the point. The insurance company wants to intimidate you with the game of the appeal process. The process does not have to be complicated. Remember this is a team sport and we are here to help. Reach out to us!