Working Through Your PPO Insurance Denial

A PPO Insurance denial of your medical services occurs, and you are left wondering what you can do to get them covered. Depending on the services, all is not lost.

Recall back in the section about "medical necessity". Your healthcare services are reviewed by nurses, therapists, and physicians to insure they meet medical necessity criteria based on evidence-based guidelines (EBG), medical policy and community standards. If your request does not meet the criteria, after its initial review, it will be denied.

What have been your PPO Insurance denial solutions; what have you done with it so far? Do you want to comment, or have a question about what else you can do?

Your insurance carrier will forward to you and the ordering physician a Letter of Denial which will explain the actions you can take should you disagree with the outcome of the review.

If you and/or your ordering physician have requested a reconsideration of the initial PPO Insurance denial, the request will be forwarded to a new Physician Advisor for review. Each Physician Advisor who reviews the case must be certified/specialist in the area being requested; for example, a brain surgeon will not review a request for a hysterectomy, only a specialist in obstetrics and/or gynecology may review the request for a hysterectomy.

Should your request be denied on reconsideration, you and your physician will again receive a Letter of Notification from your insurance provider again instructing you in action you may take should you disagree with their decision. At this point, you will be advised that you may request an "appeal".

If you do request an appeal, any new information you and/or your physician provide will be forwarded to a new Physician Advisor. As with the prior Physician Advisors, this new Advisor will examine all information submitted by you and/or your ordering physician. They will determine if your request meets the community standards of practice, medical policy/guidelines or has supporting EBG. If the new Physician Advisor is still unable to determine if your request is better than the current standard of practice, your request may be denied a third and last time at this appeal level.

A final letter will be issued by your insurance carrier. It will refer you to the appropriate organization within your State which may consider your request and whether the review process was conducted in a fair manner. If this organization determines that the insurance provider did conduct a fair review and that the request does not meet the community standards of practice, the agency will provide you and your insurance provider with a letter which states that your request has been denied at this final level of review.

Here's an example:

Let's imagine that you had a tragic skiing accident. In the accident, you sustained a broken leg. Your surgeon repaired the fracture and recommended the use of a bone growth stimulator to help the fracture heal quicker. He/she submits the request to your insurance provider.

A Review Nurse working for your insurance carrier receives your request and begins to research whether the request meets the EBG (Evidence-Based Guidelines), medical policy or community standards for a person with your diagnosis. He/she is unable to find supporting evidence so he/she forwards your request to his/her Physician Advisor who specializes in orthopedic medicine. The Advisor is unable to find information to support your request and a PPO Insurance denial is issued.

Your physician re-submits the request without providing any additional clinical information or evidence. The request is again processed by a nurse who immediately forwards it to a new Physician Advisor. This new orthopedic Physician Advisor is unable to find any information to support the request. A second PPO Insurance denial is issued with instructions on how to request an appeal.

Your physician receives the letter and, again, without adding any additional information, submits your request at the appeals level. For the third and last time the request is submitted to another orthopedic specialist. Unfortunately, there isn't one scrap of information which will support your need for a bone growth stimulator. Your request is denied at the appeals level.

Frustrated, you submit all the letters of PPO Insurance denial with your physician's request for a bone growth stimulator to the appropriate State Insurance Regulator's department for consideration. The State department researches the methods your insurance provider used in considering your request, reviews the clinical information available and, unfortunately does not find any errors in the review process. The PPO Insurance denial is upheld by the State reviewing organization.

What could have been done differently?

In this case, if your physician submitted a request for a bone growth stimulator but did not provide a reason why you needed it, and continued to submit the same request over and over again, it should come as no surprise to you that the same result (the PPO Insurance denial) will occur.

If you or your physician provided additional information which would support the reason you needed the bone growth stimulator, this could have helped the insurance carrier provide you an approval for your request.

Let’s say that, after the initial PPO Insurance denial your physician submitted an article which showed the effectiveness in healing fractures exactly like yours for people who smoke and are diabetic, and your physician provided additional clinical information that showed you have smoked a pack a day for twenty years and have been an insulin-dependent diabetic for 14 years. There is a community standard in place to use bone growth stimulators for cases exactly like yours! Your insurance provider would now have information which can allow them to approve the request for a bone growth stimulator, noting that the request now meets the community standard of practice!!!! Yippy!

The important thing to remember when submitting a request for reconsideration is to remove all the emotion out of your request and provide only the black and white facts! This can be hard to do, I know! But, submitting a request for reconsideration or appealing previous PPO Insurance denials with only an impassioned plea and threat of lawsuit does not help your case!!!!!

Trust me when I say that the one thing your insurance provider does not want is "free" negative publicity. It does not want to make the headlines or the eleven o’clock news…"insurance carrier denies prosthetic leg for child maimed in car accident, film at eleven……." . You know what I am talking about!!!!

But, if you do not provide sound clinical evidence to your insurance provider which will help support your request, then your provider is left with making the same decision over and over again. It is important to remember that your insurance provider is considering if your request is "better than the community standard of practice" and whether it is "medically necessary".

On any given day, a new surgical technique or drug is introduced which claims to be the latest and greatest "cure". As you can imagine from the news reports, a year or two after they are introduced, the FDA (Food and Drug Administration) may discover that they have an unacceptably high mortality rate.

Your insurance provider must examine each of these new "cures" and "treatments" to determine if they are, in fact, better than what is currently (and effectively) being used as the community standard. Your insurance provider has just as great a liability for approving something that they know to be unsafe as they do for denying something that is the standard of practice.

Important Resource for State Insurance Regulators (state-by-state)

State Insurance Regulators for Filing Healthcare Complaints provides a state-by-state directory to help you find your state's insurance regulator. Go directly to the website for your state to learn more about how to file a complaint against an HMO or PPO provider.

Return to DENIED, Now What Happens?

HOME

Contine to Understanding the HMO Denial Process