ThatFLGuy
Member
So, your doctor orders tests, procedures, or medical equipment, and your insurance says no. What do you do?
Section 1
1) Call the insurance company and demand to speak with the Hippa Compliance/privacy officer (They have to have one by law)
2) Demand the names of everyone accessing your medical records who decided to deny. (You have the right to know)
3) Most of this will result in a decision change very quickly. There are a few reasons to do this.
Section 2
1) Medical professionals are almost always required to be credentialed in the state where you, the patient, live.
2) Most people making denial decisions are not credentialed that way or are not specialists in advanced fields of medicine.
3) The person or persons who made the denial decisions will be liable for any violations of the Patient Rights Act and they do not want to be
4) The Insurance company doesn't ever want a report sent to the US Office of Civil Rights (OCR.GOV) as a HIPPA violation.
***NEW information ***
1) Request an appeal with all the information from section 1
2) The second an insurance company denies your appeal you have a right to a fair case hearing. This means you get to plead your case in front of a disability Judge who doesn't work for the Insurance company. The insurance company will have to get a doctor from your area and justify the denial decision. AGAIN they do not want to do this but are required to by LAW. EVERY PERSON IN SECTION 1 will be required to testify as to the denial of service.
This also means that your doctors who ordered the test, procedures, or medical equipment will be called for your defense. If you have a social worker this is also a huge +++
Now, back to section 2 point 1. In 98% of cases The insurance company must have someone on the team/teams that made a denial decision is credentialed within the profession of medicine. IE if you got Urology supplies denied they must have had a urologist with an MD/DO to make that decision. 60% of the time That doctor MUST BE LICENCED TO PRACTICE WITHIN YOUR STATE.
This is not foolproof but Someone who worked for decades within the insurance industry wrote most of this life hack and proved that it does work.
I hope this helps someone.
Section 1
1) Call the insurance company and demand to speak with the Hippa Compliance/privacy officer (They have to have one by law)
2) Demand the names of everyone accessing your medical records who decided to deny. (You have the right to know)
3) Most of this will result in a decision change very quickly. There are a few reasons to do this.
Section 2
1) Medical professionals are almost always required to be credentialed in the state where you, the patient, live.
2) Most people making denial decisions are not credentialed that way or are not specialists in advanced fields of medicine.
3) The person or persons who made the denial decisions will be liable for any violations of the Patient Rights Act and they do not want to be
4) The Insurance company doesn't ever want a report sent to the US Office of Civil Rights (OCR.GOV) as a HIPPA violation.
***NEW information ***
1) Request an appeal with all the information from section 1
2) The second an insurance company denies your appeal you have a right to a fair case hearing. This means you get to plead your case in front of a disability Judge who doesn't work for the Insurance company. The insurance company will have to get a doctor from your area and justify the denial decision. AGAIN they do not want to do this but are required to by LAW. EVERY PERSON IN SECTION 1 will be required to testify as to the denial of service.
This also means that your doctors who ordered the test, procedures, or medical equipment will be called for your defense. If you have a social worker this is also a huge +++
Now, back to section 2 point 1. In 98% of cases The insurance company must have someone on the team/teams that made a denial decision is credentialed within the profession of medicine. IE if you got Urology supplies denied they must have had a urologist with an MD/DO to make that decision. 60% of the time That doctor MUST BE LICENCED TO PRACTICE WITHIN YOUR STATE.
This is not foolproof but Someone who worked for decades within the insurance industry wrote most of this life hack and proved that it does work.
I hope this helps someone.
