Haris Ashley
Dealing with insurance companies can be a tricky business, especially when it comes to determining what is deemed medically necessary. Most health plans will not pay for services that they do not consider medically necessary, such as cosmetic procedures or experimental treatments. However, what is considered medically necessary can vary between Medicare and private insurers, and even between states. If your insurance plan refuses to approve or pay for a medical claim, you have the right to appeal the decision, and it is recommended to seek the help of a health insurance lawyer to improve your chances of success.
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What You'll Learn
Understanding 'medical necessity'
Understanding medical necessity
The definition of "medical necessity" or "medically necessary" varies depending on the context. Generally, it refers to health care services that a healthcare provider, exercising prudent clinical judgment, would provide to a patient. These services must be for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms. They must also be in accordance with generally accepted standards of medical practice and clinically appropriate in terms of type, frequency, extent, site, and duration.
Medicare, for example, defines "medically necessary" as: "Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice." This includes services that are needed to evaluate, diagnose, or treat an illness, injury, disease, or its symptoms, and that are in accordance with generally accepted standards of medical practice.
Private insurers that offer non-Medicare plans can set their own criteria for determining medical necessity, but they must comply with state and federal benefit mandates. For individual and small group health plans with effective dates of January 2014 or later, this includes coverage for essential health benefits defined by the Affordable Care Act. However, states determine the specific services covered for each benefit, so there is some variation from state to state.
It is important to note that health insurance plans typically only provide coverage for health-related services that they deem to be medically necessary. This means that the insurance company decides whether a particular service is considered medically necessary and necessary to maintain or restore the patient's health or treat a diagnosed medical problem. If a service is not deemed medically necessary, it is unlikely to be covered by the insurance plan.
Additionally, "covered" does not mean that the insurance plan pays for the entire cost. Patients are usually responsible for their required cost-sharing, such as copays, deductibles, and coinsurance, even for covered services. They may also be responsible for some of the costs until they meet their health plan's out-of-pocket maximum for the year.
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Appealing a denial
If your insurance company denies your request to cover medically necessary treatment, you have the right to appeal their decision. This can occur if your insurance company deems that a treatment is not medically necessary, which is a decision made by your health plan that your treatment is necessary to maintain or restore your health or treat a diagnosed medical problem.
Firstly, you should call your insurance provider and ask for more details about the denial and review your appeal options. You can ask your insurance agent to walk you through the appeals process, and it is important to note that each insurance company has a specific appeals process, so you will need to follow their steps carefully. You should find out what forms you need to submit and how long you have to appeal the decision. It is also worth checking that the denial was not due to an error on your service provider's part, in which case they can resubmit the claim with the correct information.
You can then submit an internal appeal directly to your insurance company, asking them to reconsider and reverse their decision. You will need to fill out all the required forms and write an appeal letter. The letter should be straightforward, clear, and concise, explaining why you should get coverage. If your claim is urgent, your insurance company must speed up this process. If your first appeal is denied, additional levels of appeal will be outlined in your denial documents.
If your internal appeal is denied, you can take your appeal to an independent third party for an external review. This means that the insurance company no longer gets the final say over whether to pay a claim.
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Seeking an IMR (Independent Medical Review)
An Independent Medical Review (IMR) is a process in which expert independent medical professionals review specific medical decisions made by an insurance company. In California, the Department of Insurance (CDI) administers an IMR program that enables insured individuals to request an impartial appraisal of medical decisions within certain legal guidelines.
The Steps Involved in Seeking an IMR
- The Agreement: To initiate the IMR process, you must provide written consent indicating your willingness to participate in the program. The application form includes a consent statement that, once signed, grants permission for the IMR organization to access your medical records.
- Eligibility: After submitting your completed application, the CDI will determine if your request qualifies for the IMR program. If it does, you will be notified, and the process will continue. If your request does not qualify, it will be referred to the complaint/mediation program within the CDI.
- Review Process: Once your request is deemed qualified, the CDI notifies the health insurance company, which is required to provide the IMR organization with all necessary documents, including medical records, within three business days. The IMR organization then conducts its review and provides a written determination.
- The Determination: The written determination from the IMR organization will be provided to you, your insurance company, and the Insurance Commissioner. This document will include your medical condition, the important documents reviewed, and the relevant findings.
- Implementation: Upon receiving the IMR determination, the Insurance Commissioner immediately adopts the recommendation from the IMR organization.
It is important to note that the IMR process cannot be used for decisions based on coverage issues. It only applies to disputed healthcare services related to the practice of medicine and does not involve coverage disputes. Additionally, you must exhaust the internal appeals or grievance process of your insurance company before applying for an IMR with the CDI.
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Consulting a health insurance lawyer
Dealing with insurance companies for medically necessary treatments can be a challenging and complex process. Health insurance plans provide coverage only for services they deem medically necessary, and they may deny claims for a variety of reasons, including lack of pre-certification, errors on claim forms, or deeming a treatment as experimental. If you are facing issues with your insurance company, consulting a health insurance lawyer can be a crucial step in protecting your rights and ensuring you receive the coverage you are entitled to. Here are some reasons why and when you should consider consulting a health insurance lawyer:
Understanding Your Options and the Appeals Process:
If your insurance company denies your claim for medically necessary treatment, you have the right to appeal the decision. The first step is to understand the reason for the denial, which the insurance company should provide in writing. An experienced health insurance lawyer can help you interpret this correspondence and determine your best course of action. They will explain the appeals process, including any time limits and specific procedures required by your insurance provider. This knowledge will empower you to make informed decisions about your next steps.
Guiding You Through the Legal Process:
Health insurance lawyers are experts in insurance law and can provide crucial guidance if you need to take legal action against your insurance company. They will help you navigate the complex legal system, ensuring that you comply with all necessary procedures and deadlines. This may include assisting with the preparation and filing of legal documents, representing you in court, and communicating with the insurance company on your behalf. Their expertise can significantly increase your chances of a successful outcome.
Protecting Your Rights and Best Interests:
Health insurance lawyers are advocates for your rights and will work to ensure that your insurance company treats you fairly. They will scrutinize the actions of the insurance company to identify any instances of bad faith or unfair practices. By holding the insurance company accountable, they send a clear message that you have support and representation in upholding your rights as a policyholder. This can be especially important when dealing with a debilitating medical condition, as it allows you to focus on your health and recovery while they handle the legal aspects.
Maximizing Your Chances of Claim Approval:
Health insurance lawyers are skilled in interpreting insurance policies and understanding the specific terms of your plan. They can apply this expertise to your case, ensuring that your claim is presented in the most favourable light and addressing any potential areas of dispute. By utilizing their knowledge of what insurance companies look for in approving claims, they can maximize the likelihood of your claim being accepted during the appeals process or in court if necessary.
Providing Emotional Support and Peace of Mind:
Dealing with insurance companies during a medical crisis can be emotionally draining and stressful. Health insurance lawyers understand the human element involved in these situations and provide a supportive presence throughout the process. They offer reassurance and peace of mind by handling the bureaucratic aspects of your case, allowing you to focus on your health and well-being. This compassionate approach is an important aspect of their service, recognizing that each case involves a person or family facing challenging circumstances.
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Filing a legal action in a court of law
If you are considering filing a legal action against an insurance company in a court of law, there are several important steps to follow and factors to consider. Firstly, it is crucial to understand your insurance policy, including your rights, coverage limits, and any exclusions. This will help you determine if the insurance company has violated any state laws or acted in bad faith. Examples of bad faith insurance practices include delaying or denying payments without a valid reason, overall uncooperative behaviour, and failing to honour coverage that applies to your circumstances.
Before rushing to court, it is advisable to attempt alternative dispute resolution methods such as mediation or arbitration. Mediation involves a neutral mediator facilitating discussions between both parties to reach a mutually satisfactory agreement. On the other hand, arbitration involves an arbitrator making a binding decision, but this option may have limitations on the amount awarded and the types of damages covered. If you are unsure about the best course of action, consulting with a lawyer who specialises in insurance cases can provide valuable guidance.
If you decide to proceed with a lawsuit, you will need to gather evidence to support your claim. This includes documenting all communications with the insurance company, as well as obtaining relevant records such as medical records, repair estimates, and correspondence. An attorney can help ensure that all necessary evidence is properly collected and presented in court. It is important to be mindful of the statute of limitations, as each state has its own deadline for filing a lawsuit, and there may be time limits for specific types of claims.
When filing a complaint against the insurance company, you will need to outline your grievances and the relief sought. This will be followed by a discovery phase, where both parties exchange information and evidence. There may then be attempts at negotiation or settlement to resolve the dispute without a trial. If a settlement cannot be reached, both parties will need to prepare for trial by gathering witnesses, experts, and additional evidence.
During the trial, the case will be presented before a judge or jury who will make a decision based on the evidence presented. If either party is dissatisfied with the outcome, they have the right to appeal the decision, although this can lead to increased court costs. It is important to remember that filing a lawsuit should be a last resort after exhausting all other options, as the process can be complex and time-consuming.
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Frequently asked questions
"Medically necessary" refers to a decision by your health insurance plan that your treatment, test, or procedure is necessary to maintain, restore, or treat a diagnosed health issue. Most health plans will not pay for services they deem not medically necessary, e.g., cosmetic procedures.
You have the right to appeal the decision. You can start by filing an internal appeal with the insurer, providing a detailed letter explaining why the denial was improper. You can also seek external reviews, such as an IMR (Independent Medical Review), where an independent medical professional assesses if the insurance company's decision was justified.
Contact a health insurance lawyer to guide you through the process, as IMR decisions can be challenging to overturn. Once you complete the IMR application, send your written consent to allow the IMR medical professionals to access your medical records.
If the IMR organization determines that the insurance company acted improperly, the CDI or DMHC will issue a written decision compelling the insurance company to change its conduct. However, note that an adverse IMR determination does not prevent you from seeking relief for treatment deemed medically necessary.
Yes, another option is to file a legal action in a court of law. A lawsuit can exert immediate pressure on the insurance company to reassess its denial and strengthen your position. Consult with an experienced health insurance lawyer to determine the best course of action for your specific situation.
