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Avoid Healthcare Coverage Disputes

Dear Colleague,

It seems that one recent byproduct of our videos involves calls from people who have healthcare coverage disputes we can’t take on for them for a variety of reasons which I’ll explain below.

It is always best to avoid disputes if at all possible. My staff and I have an outstanding track record of keeping our subscription clients out of disputes. It is not easy. The best way to avoid disputes is to:

  • Very carefully select your coverage. Buyer’s remorse can be distressing.
  • Take the time to understand your benefits.
  • Stay in-network.
  • Follow the Plan’s rules.
  • Maintain excellent records of communications with your insurer.

We know it isn’t always possible to avoid disputes. The video we did about the air ambulance emergency evacuation is one such example. The insurance company in that situation did not honor its contractual obligation.

Years ago we represented a client in a dispute about coverage in a clinical trial. The insurance company had recently published criteria about what it would cover and the denial was inconsistent with the criteria. I tried multiple times to communicate with the insurer in the hopes of avoiding appeals and hearings to no avail. As a result, we spent weeks preparing documents and testimony. Although I was in charge of the hearing from the client’s perspective, he also retained a litigation attorney to join us at the proceeding. The attorney also felt an obligation to review the entire file with me, which is understandable, but another expense for our client. The result was positive. Within five minutes of opening the hearing, the Medical Director of the company said “What are we doing here? We have to cover this.” What a waste of time, effort and money.

And then there is prior authorization hell which can leave a patient and family in a very precarious situation, especially when a procedure is scheduled and prior authorization has not yet been granted.

We see, however, some types of disputes occurring again and again, many of which are avoidable:

  • Deliberately seeking services out-of-network believing one can get the insurer to pay more of the provider bill than they are obligated to pay. And, worse, receiving out-of-network services with no out-of-network benefit (emergency care excluded).
  • Having a loved one admitted for alcohol, substance abuse or to a mental health treatment facility before the stay is authorized.
  • Having issues with coverage which is not Affordable Care Act compliant and/or otherwise under or un-regulated by state insurance departments.

For the most part, we are able to keep our subscription clients out of disputes because we assist them in selecting coverage, we know their coverage, we are authorized to contact the insurer or provider on their behalf, and the client typically keeps us informed of any significant medical appointments, procedures or surgeries.

Unfortunately, people often contact us too late to be helpful with their dispute. They’ve let the matter age, or already appealed and lost themselves, sometimes multiple times, or simply don’t have a case. And, on a practical level, because a dispute can be like litigation, we can’t staff effectively to provide dispute resolution services year-round. Our subscription advocacy and coverage transition clients will always be our priority. And, sadly, sometimes there isn’t enough money at stake to fight Goliath in a cost-effective manner and we have too many obligations like payroll and benefits to assume the risk of working on a contingency basis.

That said, when someone comes to us at a time of year we have capacity, and they have a strong and recent case, we’ll often take that on.

The healthcare field can feel very combative. After all, there is always money at stake. We hope the videos and accompanying email blasts help you become more informed so you can avoid healthcare coverage disputes.

Thanks and take good care.