INTERVIEW ON THE PRICE OF BUSINESS SHOW, MEDIA PARTNER OF THIS SITE.
Recently Kevin Price, Host of the nationally syndicated Price of Business Show, interviewed Dr. David Wilcox.
A recent study of Affordable Care Act (ACA) plans found that even when patients received care from in-network physicians and hospitals approved by these same insurers the insurance companies in 2021 denied, on average, 17% of claims. One insurer denied 49% of claims in 2021; another’s claim denial rates hit an astonishing 80% in 2020.
Why would a company that you are paying good money to insure your healthcare deny your claims when you are seeing in-network providers and getting your care at in-network facilities? The healthcare insurance companies play a shell game. They take your premium dollars and then decide how they will pay for your care. It’s a complex set of rules that vary from healthcare insurer to healthcare insurer and these rules are shrouded in secrecy and difficult to understand. This is not an accident. Healthcare insurers have a lot of power and have built this web of complexity to control the playing field. They hope that you will tire in your pursuit of trying to get them to pay for your care and just open your wallet and get it over with.
I recently met a young lady who had recently given birth. After the baby was born the social worker at the hospital gave her a list of agencies where she could apply for benefits. One of those agencies, The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age 5 who are found to be at nutritional risk. During the application process, the WIC representative filed a Medicaid application without telling the young mother. Once the insurance company found out about the Medicaid application they cancelled her insurance on the spot and refused to pay for her childbirth costs. Mind you this is after the baby was born while she was fully covered by the insurance company! I encouraged her to appeal the insurance company’s decision as I knew she would win. I even offered to help, but as far as I know, she never did and now starts life with a huge healthcare induced debt.
This is all too common as people only appeal claims at the rate of 1 in 500 denials. This may be because they are unaware of how to file an appeal. There are two types of appeals, internal and external appeals. When receiving a denial the insurance company must give the insured information on how to file an appeal. With an internal appeal, the rate of success for the insured is roughly 40%. The rate of success increases with an external review which is handled by a third party as the insurance company has no say in the outcome of the appeal and must abide by the decision of the third-party company. Of course, all of the denial process has to happen in a timely manner.
You have up to six months (180 days) after finding out your claim was denied to file an internal appeal. If the denial is for a medical reason, ask your healthcare provider to contact your health plan and request reconsideration of your claim based on additional information that your healthcare provider can supply. If your life, health, or ability to function could be jeopardized, you can request that the appeal be reviewed on an expedited basis. Ask your insurer how to file an internal appeal by contacting the customer service number provided on your insurance card or · write a letter to your health plan requesting an internal appeal. Make sure to include your name, claim number, and health insurance ID number. You should include any additional information, such as a letter from your provider, that helps support your claim.
If your insurer does not change its decision as a result of the internal appeal, an external review can be requested. An external review is performed by an independent review organization. You must ask for an external appeal within a specific amount of time after receiving the decision of your internal appeal. Your internal appeal notice should provide information on requesting an external review. Your state’s insurance regulatory agency is usually in charge of the external review process. The external reviewer will provide you and your insurer with written notice of its decision within a specific amount of time after receiving the review assignment. If the external review results in a reversal of your insurer’s decision to deny, the company must approve benefits for the covered services.
It baffles me why the insured people of this country don’t take the steps needed to appeal the insurance companies’ denial and have them cover the cost of their healthcare. Once you get flagged as someone who appeals denials you will get fewer denials. Hopefully, the steps in this article will arm you with the necessary information to successfully appeal an insurance company denial and get the quality care that you and your healthcare team are trying to deliver. A copy of regulatory state insurance agencies can be found here: https://content.naic.org/sites/default/files/regulator-membership-list.pdf
You can purchase Dr. David Wilcox’s book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival on Amazon at the following link https://lnkd.in/diZKYC2
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Twitter – https://twitter.com/DrDavidHelps
According to a statement, “Healthcare is complex and that is not an accident. It is complex by the healthcare entities vying for your healthcare dollars. Covid has exacerbated the American Healthcare System, which was fragile, to begin with. Many clinicians are leaving healthcare due to burnout. How does the average layperson navigate the complexities of the American Healthcare System where a prescription could cost you $5 at one pharmacy and $500 at another? What does the average layperson do when their insurance company rejects their claim? Proactive education of the American Healthcare System prior to accessing it is the key to safely navigating the healthcare system. Until now, little information has been available to provide the layperson with the knowledge they need to be a better partner in their health care. Dr. David Wilcox’s book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival” is a game-changer and will provide you with the skill set you need to navigate the American Healthcare System.
Dr. Wilcox is a Doctorate prepared nurse who also holds a Masters in Health Administration and is Board Certified in Nursing Informatics. Dr. Wilcox has 28 years of healthcare experience in which he worked as a bedside nurse, hospital administrator, and in healthcare information technology which has helped him to develop his unique perspective on the American Healthcare System.
Dr. Wilcox is the author of the book “How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival (2021)” available at https://www.amazon.com/dp/0578878364
Dr. Wilcox currently resides in North Carolina with his wife and their three dogs.
Dr Wilcox’s website: Dr. David Wilcox – Healthcare, American Healthcare System (drdavidwilcox.com)
LISTEN TO THE INTERVIEW IN ITS ENTIRETY HERE