You HAVE The Right To Appeal!

It’s easy to write an appeal…

The option to appeal is a right you have when you disagree how services (claims/prescriptions/benefits) are processed with the carrier.  When you begin to write the appeal there are certain pieces of information you should include to enable the appeal to be reviewed.   

1.    Always have the word "appeal" somewhere in the letter.

2.    Make sure you include the policyholder's insurance information (member ID or social security number, date of birth).  You will also need to include the patient name and date of birth.  See example below:

Policy Holder- John Smith
ID# xxx-xx-xxxx
DOB xx/xx/xxxx
Patient Judy Smith
DOB- xx/xx/xxxx

3.    Make sure to include all dates of service you are appealing in the letter.

4.    Include the reason you are appealing.  (Tell your story/situation)

5.    Include any supporting documentation from your doctor or health professional.

An appeal can take up to 30 days. The explanation of benefits (EOB) gives the information where to send the appeal to. Remember to keep copies of what you send for reference or if you would want to appeal on a higher level with the carrier. Carriers notify in writing directly to the member when the appeal is received and also when the resolution on appeal has been rendered.

The Customer Care Team is available to help with questions on the appeal process.  Please feel free to contact us  Direct  (937-) 260-4300 or toll-free  877-635-5372

Your Right To Appeal

Health care and the processing of claim is not a perfected science. Claims get coded incorrectly by providers’ offices, sent with incorrect ID information, or processed incorrectly through benefit plans. For health care consumers, it can take some digging and effort in order to get these matters corrected. Sometimes, it even takes an appeal (or multiple appeals).

Based on a recent article by Money Magazine:

·         15% of health claims are denied

·         14% of denied claims are appealed

·         50% of appeals are successful

As patient advocates for our clients, the McGohan Brabender Customer Care Team acts as the patient advocate – mentioned in section 4 – to help identify errors, craft appeals, and escalate the battle when necessary.

Make sure to check out Money Magazine’s article for more information on your right to appeal!

COBRA/FMLA Compliance

Recently, a court case ruled on the how FMLA, STD, and COBRA work.

The Family and Medical Leave Act (FMLA) ‘provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.’ This act ‘applies to all public agencies, all public and private elementary and secondary schools, and companies with 50 or more employees. These employers must provide an eligible employee with up to 12 weeks of unpaid leave each year for any of the following reasons:

·         for the birth and care of the newborn child of an employee;

·         for placement with the employee of a child for adoption or foster care;

·         to care for an immediate family member (spouse, child, or parent) with a serious health condition; or

·         to take medical leave when the employee is unable to work because of a serious health condition.

Employees are eligible for leave if they have worked for their employer at least 12 months, at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles. Whether an employee has worked the minimum 1,250 hours of service is determined according to FLSA principles for determining compensable hours or work.’

In the court case, an employee went on FMLA. Once FMLA had run out, their employer put them on STD without offering them COBRA coverage. At the end of STD, the employer offered the employee COBRA coverage. However, the carrier refused to reimburse the employer for medical expenses incurred during the employee’s STD coverage. The employer argued that the requirement to be on FMLA, work 40 hours a week, or be on COBRA was only a condition for initial eligibility, but the court ruled in favor of the carrier, and the carrier was not responsible for reimbursing the employer for the employee’s medical expenses incurred while on STD.

For more information on this case, check out Plan Sponsor. For more information of FMLA, check out the United States Department of Labor.

FAQ: I have exhausted all appeals options through my insurance carrier. Is there anything else that I can do?

Medical benefits are not an exact science, and sometimes it is necessary to appeal the processing of your claims with your insurance carrier. Should you receive a denial to your claim from your insurance carrier, exhaust all appeals processes with you insurance carrier, and still believe that your claim should be reprocessed, you are able to appeal through your state’s department of insurance.

The Ohio Department of Insurance is able to provider consumer information and can investigate complaints involving insurance companies and agents. As noted on their site, the department cannot:

·         Act as your legal representative, or give you legal advice

·         Recommend insurance companies or HMOs

·         Force a company to give you what you want if no laws have been broken

·         Make determinations about medical necessity

·         Address problems with your employer's self-funded health plan, unless the plan involves an insurance company, an HMO or an independent administrator that is licensed with the Department

If you have exhausted your appeals process with your insurance carrier and choose to appeal through the Ohio Department of Insurance, you can do so by completing the following complaint form and submitting it per the instructions provided by the ODI.

Consumer Complaint Form