Volume 17 · Issue 3 · May/June 2007 | Download PDF
by Jeff Cain, MD
Insurance – Questions and Answers
Success stories from someone who has been there, done that
How can you win when the insurance company says ‘No’ ?
Jeff Cain is a bilateral, below-knee amputee and a veteran of many insurance battles. He also founded the Colorado Coalition of Working Amputees, which, through grassroots efforts, made Colorado the first state to pass prosthetic parity insurance legislation in 2001. A member of the Amputee Coalition Board of Directors, he also helped start Amputee Coalition’s Action Plan for People with Limb Loss (APPLL) initiative, which has helped pass parity legislation in six states and is working on legislation in 24 more.
In addition to these legislative battles, Cain has plenty of personal experience in the trenches of insurance warfare.
“The flat spot on my head is from beating it against the wall of insurance rules,” laughs Cain. Still, he adds,
“I may have a flat spot on my head; but fortunately, I also have two-brand-new prosthetic legs.”
He admits it’s sometimes hard to get insurance companies to cooperate, “but by understanding the rules and by being polite, professional, persistent, and gentle but firm with them, I’ve been able to get adequate coverage for really good prosthetics. And I’ve been able to use the prosthetist of my choice.” With that in mind, Cain offers three lessons from his decade-long experience of being an amputee dealing with insurance companies.
1. Choose your insurance company wisely.
When choosing your insurance, it’s critical to carefully review and familiarize yourself with the benefits that each insurance company allows and which healthcare professionals they allow you to visit in- or out-of-network. You need to know what benefits and choices each plan offers, Cain explains, so you can choose the prosthetic devices and access to providers best suited for you.
Next, call each of the companies and talk with a representative. Get a sense of how they will deal with you as a customer. Ask them for confirmation that the plan outlined in their written materials is what you will actually get if you sign up. Also, confirm that your prosthetist is included on their providers list. Most importantly, Cain stresses, “Write down the date and the time and the name of the person you talked to, because that’s going to come up later.”
Cain explains that he chose a plan that included the prosthetist he’d used for a long time. “But when it came time to use the service,” he recalls, “the insurance company said no, they no longer allow that prosthetist to be covered.” But Cain had documented his conversation with an insurance representative who had told him that his prosthetist was included in the plan.
“Although they initially denied me, after I provided the information about who I spoke with, when we spoke and what their representative said, and I stressed to them the importance of this decision, they covered my benefit as inplan coverage for that prosthetist for that year,” Cain says.
Also, when you talk to an insurance representative and you are denied on something you believe you should get, ask to speak with a supervisor. Often, Cain says, “The first person you talk to on the phone may say no because he doesn’t understand the more complex nature of your need. Most people really don’t understand prosthetic needs or devices. So I will ask who I can speak to in a supervisory capacity. And I will ask for the supervisor’s supervisor.” And he will keep asking until he speaks with someone who has the technical background to be able to understand his request.
So the first lesson is to investigate fully, choose wisely, keep all your interactions professional and document everything that you do.
2. Just because they say ‘No’ doesn’t mean you aren’t going to get your way.
Insurance companies are businesses, and no business likes to pay out money. To avoid paying, insurance companies put levels of bureaucracy and walls of paperwork between you and your claim. And the first representative you speak with when trying to file a claim is often unfamiliar with the specifics of your particular need. All of this can be very discouraging if you’re trying to get the coverage you believe should rightfully be provided without so much hassle. If you’ve navigated the bureaucratic maze and cut through the red tape and paperwork only to have your claim denied, Cain has some simple advice: Don’t give up.
Cain says that having a claim denied on the first application is not unusual. “If you give up the first time, you’re not going to get your way,” he points out. It’s important to remember that, for every denial of an insurance claim, there is an appeal process.
Cain provides another example from his own experience. The Colorado Coalition of Working Amputees had gotten the law passed that required insurance companies to pay 80 percent of the cost for prosthetics with no cap. The law specifically defines the prosthesis as a replacement in whole or in part for a missing arm or leg.
Despite this legal definition, says Cain, “My insurance company said that they didn’t have to cover hands or feet. As ridiculous as that sounds, they initially denied payment for my feet. They said they would cover the leg, which they defined as the socket.”
But Cain was determined and persisted with his claim. “As soon as I was able to appeal their denial and quote them the law in Colorado, they were able to see things my way and provided the feet for my prosthetics,” he says. Cain later had a similar denial for a replacement prosthesis. “They didn’t want to cover it, but by appealing with medical documentation they covered my prosthesis.”
Besides interpreting legal language in a way that allows denial of claims, insurance companies may also deny a claim by saying something is experimental or not medically necessary. Claims for computerized prostheses are often denied on this basis, says Cain.
“They will seize on absurd things in the language, and they may use different words about medical necessity to explain the denial, but you can appeal,” Cain explains.
“The Amputee Coalition and your prosthetist can help you define ‘medically necessary’ in a way that should allow you access to appropriate technology.” (For another example of a successful appeal, see the article by Amputee Coalition Chairman David McGill on page 15.)
3. ‘No’ isn’t the last word. Appeal to the state insurance commissioner.
If the appeals process fails, but you have a medical necessity for your claim, you can then appeal to your state insurance commissioner. Insurance commissioners make certain that insurance companies provide services in a way that’s legal and meets the spirit and intent of their state’s laws.
Cain again emphasizes the importance of saving your documentation. “Save all your documents and letters from the insurance company denying the service and put together a packet to take to your insurance commissioner’s office,” he says. “If the commissioner finds that the insurance company has been egregious or willful in denying coverage that they deem reasonable, there are penalties, with up to triple damages to the company.” If you win your appeal, the commissioner can also make certain that the insurance company won’t do this again to you or anyone else in the future.
Cain says that after he learned his prosthetist wouldn’t be included by his insurance company as an in-network provider, he confirmed that his prosthetist could be allowed out-ofnetwork if he chose a slightly more expensive plan. So he took the more expensive plan. But when the time came to use his insurance for a new prosthesis, his insurance company had other ideas. Cain recalls, “They said, ‘Oh, outof- network benefits are capped at 40 percent and a total of $4,000 per year,’ which is different than the law in our state.”
He appealed, informing his insurance company that they were in violation of state law. They still denied his appeal. He resubmitted his request, with documentation of medical necessity and a copy of the state law showing that insurance companies are required to pay 80 percent of the cost for prostheses with no cap. Again, the insurance company denied his appeal, apparently believing that ended the matter.
But Cain took his appeal to the insurance commissioner’s office. After the commissioner reviewed Cain’s documentation, the insurance company was cited as being in violation of the law. “Not only did they have to cover my prosthesis,” says Cain, “they had to contact every person who had their insurance product and tell them that their interpretation of the law had been in error. If they have any future violations, they will be considered in willful violation, which will come with significant penalties.”
Be Gentle but Firm
In conclusion, to make sure your insurance company will work with you, do your homework and know your plan. Document all contact with them. Remember, even though your medical necessity is extremely personal to you, it’s just another business matter to the insurance company – one in which they’d prefer not to pay out any money.
When you know you’re right, don’t give up. But don’t lose your temper. Getting angry won’t help your case. Instead, be polite, be professional, be persistent and be gentle but firm. Be helpful, if you can. For instance, provide them information about how a rule should be legally interpreted, and do so in a nonthreatening way.
Insurance, Cain says, is like a complex puzzle, with thousands of pieces that all look the same. But by being persistent, it’s possible to reach an agreement even if the insurance company initially says no. “And because of that,” Cain says, “I can afford a leg to stand on.”
About the Author
Jeffrey J. Cain, chief of family medicine at The Children’s Hospital in Denver, has been lobbying for many years for the right to include prosthetic coverage in medical insurance. He is a board member of the Amputee Coalition and chairs its Public Policy and Advocacy Committee.