Insurance Claim Denied? How to File a Medical Appeal

Video Transcript

Joyce Griggs: Hello everyone. I'm Joyce Griggs for United States of Healthcare. Welcome to our conversation with our insurance experts, Dr. Alan Feren and Jordan Shields. Dr. Feren and Jordan are here today to talk with us about how to write a letter of appeal and what happens when one of your insurance claims have been denied.

Dr. Feren has over 50 years of experience on both sides of the stethoscope as a patient, as a patient advocate, as a surgeon, and as a medical director for a leading insurer. Jordan Shields has many years of experience as a consultant for the insurance industry. He's written books, he's written articles, and he has worked with individuals helping them to choose insurance that's right for them and their families.

And I'm delighted to have a conversation to share with you today about how you can take charge of your healthcare when you get a denial of your claim. And we're gonna take you step by step through how to write a letter of appeal.

Jordan and Alan. Great to see you guys.

Jordan Shields: Great to be here.

Joyce Griggs: So, okay, there are some dos and don'ts, right? You have like eight do's and four don'ts, or, anyway, who's counting? But there are a number of steps that we can take, right?, to get ready when we've gotten a denial. So, let's just talk about it a little bit. Just go back to what has happened, and maybe set the stage for us a little bit, and then what, what we're gonna do next.

Jordan Shields: Let me do that, Alan. So you've gone, you've had a procedure, you've taken a drug, you've gone to the hospital, you've had surgery, whatever.

You get a statement from the insurance company called an Explanation of Benefits, EOB, and the EOB says, we've received this charge from this provider on this date. We've changed the numbers around a little bit, or we haven't, and then we've determined whether we're gonna cover it or not. And here's what we're gonna pay you.

What we're talking about today is that little middle part where it says, oh yeah, and by the way, eligible for reinbursement? Zero. See footnote. Footnote says, your medical claim is denied because. Fill in the blank.

So our job today is to talk about when you receive that, what do you do, how do you proceed, what steps do you take?

And the very first one, and Alan can start talking about the other ones, but the very first one is don't believe it and don't panic. Just because they say "not covered" does not mean that it's not covered. What it can mean or what it can be code for is we don't understand. We don't have enough information. We're not sure that you've clearly made your case. There's missing information. Whatever. The very busy claims examiner has this come across their desk. They're looking for, you know, to check the boxes. What have I got? What don't I have? Nah. Denied. It's easy. Then they send it back to you. As you said, Joyce, let the games begin. They send it back to you to say, okay, we did the first review. It didn't pass. You're gonna have to come back with a story. And that's when we start.

Joyce Griggs: Okay, so take a deep breath. Right? Alan said that to me before. Take a deep breath.

Alan Feren, M.D.: Take a deep breath and don't

Jordan Shields: Several deep breaths

Alan Feren, M.D.: move anything around the house. Yeah. Don't kick the dog.

Jordan Shields: And don't operate any heavy machinery for a while.

Alan Feren, M.D.: Right.

So what Jordan has alluded to is really take the time to assess the situation, look at your Explanation of Benefits, and then your Evidence of Coverage to determine what, what was done, and if that is explicitly stated in the Explanation of Coverage to be denied for whatever reason they state.

So that's first thing is try to —

Jordan Shields: Assuming, assuming they stated it. Assuming they stated it.

Alan Feren, M.D.: Yeah. And it may not be stated clearly. So take the time to try to exactly understand. And if you don't understand, talk to your person. Like, like Jordan, your broker talk to your doctor to help clear it up.

But the first thing you should not do is go directly and call the doctor's office and say, what's going on here? And how come this was denied? That's about the last thing you should consider.

Jordan Shields: Well, you could do that if you want, but we wouldn't advise it.

Alan Feren, M.D.: Yeah. So read that language very carefully.

Joyce Griggs: Okay. And I could also go to my, my HR person, right? Maybe they could help me understand it too. Cause I think what I know what happens for me anyway, I get letters like that and I immediately, I personally have an emotional response. I get upset. And when I'm in an upset state of mind, it's very hard to understand language that's not written for the everyday person.

Jordan Shields: So, yes, going to, well, first of all, go to somebody that's not you, that that gets it. I mean, it can be the doctor's office that would explain it, to somebody on the staff who's very familiar with how this works. Particularly when you're dealing with a specialist office because they're dealing with these narrow areas all the time.

If you have an HR manager at work, if assuming you have a group plan or an office manager, they may have enough familiarity with it, and if they don't, and this is especially true of small companies, often they'll say, well, let's get our insurance broker involved. Because the insurance broker has a lot of expertise in that.

I mean, I have 45 years, so the idea that an office manager's been there two weeks will try and help somebody when I can help 'em with 45 years. It's like, and that's what I'm there for, and that's what I get paid for on a continual basis. And then they can say, well, send it to me. Let's take a look at it. Maybe I can tell you right off the top what's going on here. If not, let's get the carrier on the phone and find out what's going on. But yeah, don't panic, breathe and know that you have resources, which can be pretty much anybody that's not you, cuz you're in an emotional state. Right?

Joyce Griggs: That's really, really important.

So, Alan, I know many times you've said, first off, the first step sometimes is just ensure that the, the thing is accurate, right? I mean, sometimes something, something simple like your name or, I mean, literally something as obvious as that could be wrong. Is that, is that right?

Alan Feren, M.D.: I think, yeah. It's essentially these are the so-called administrative errors that happened not too inoften with carriers.

It can be a wrong person, could be a wrong name, could be a wrong birthdate, a wrong, it could be wrong number. Yes. So all these things are very simple and so these generally managed just with a phone call to the health plan indicating what the, the correct name, birthdate, social security number, et cetera, is.

So those are the easy things, but the more difficult ones are when you're denied because of medical necessity, length of stay, wrong drug, et cetera, et cetera. So it's important to understand exactly what you're doing. Why it was denied according to the language that you can understand.

And then it's time to do your homework.

Jordan Shields: Before you go with that, I just wanna mention one thing. So remember, and I was mentioning you can use other people, sometimes you're not the best advocate for yourself. Not just cuz the emotional state, but maybe, maybe the language or whatever's, you know, whatever, there could be a lot of reasons. You can employ somebody or ask somebody to help you, but they will need to get a release from you called a HIPAA release. So the privacy and all that. But then once they have the HIPAA release and they send it to the carrier, they may speak on your behalf. They may ask questions about the claim.

I mean, even as a broker, even though it's my case, my client, and you work for my client, I cannot call the insurance company just blithely say, you know, "what's up?" I can say, When did you send out the Explanation of Benefits? You know, what was the date of that? I mean, I can ask the really basic information, but if I say, why? What are the circumstances? They not only won't tell me, but they can't tell me, oh, by the way, I have this release. So if you are gonna be bringing in somebody else, be prepared to go through a little bit of paperwork. Takes a week. No problem. Sorry Alan, go ahead.

Joyce Griggs: No, no, that's important. I just wanna underline that point because a, a patient advocate, like people like yourselves, my personaladvocate.net, you have a HIPAA release form, and then they can help with understanding what's happening with this more deeply because they can speak with your providers, whether they be the payer, the insurance company, or your doctor or whomever on your behalf. So that's really important. That's a really important point.

So, okay, so now we, we've ensured the accuracy, we've read the denial language carefully. We're assessing, you know, if it's that we're clear. We've gotten our, you know, we've lined up our team to help us. But now it's, it's homework time, right, Alan?

Alan Feren, M.D.: Absolutely. We haven't done homework for many, many years, but it's really important and the, the homework should include looking at credible resources like through the AMA, through the various specialty society just to, to find out what is the current medical situation with regard to guidelines that are, that are appropriate?

And if you find guidelines that substantiate your claim in terms of why you feel it should have been approved and not denied, then make sure you keep a record. I think, you know, go, even going back further, start a file, a special file that you have, so all, all your medical records, all the results of your tests, studies, people you've seen, everybody you've talked to, who was it, when did you speak with them? What was their phone number? Collect all that information because you're gonna need that for the long haul here. And as a, as a separate personal thing, I think it's important that when you have diagnostic imaging studies, like a CT, like an MRI, any tests, make sure you spend a few extra minutes at the facility and ask for a, a CD. Have a disk with you because if you're gonna get a second opinion, if you're gonna see someone else, they're gonna want to have that information. And it's just very, very useful.

Jordan Shields: If you don't have the CD what some medical groups are doing now, at least in my backyard I've got UCSF is taking over a lot of medical practices. But they have an online, you know, MyChart or whatever you want to call it, sometimes they can append the the X-rays or the MRI results to MyChart, which can only be accessed through login information. Makes it a lot easier for me to transfer the information to the carrier than to send a CD. Now Alan's dealing with, with last year. This is, so last year, the CD thing. Now you need, now you need the streaming.

Alan Feren, M.D.: Got news for you, buddy. It's very much, it's very much this year.

Joyce Griggs: It's very much this year.

Alan Feren, M.D.: Not everybody is, has MyChart and is in UCSF and they're multiple medical records.

Joyce Griggs: That's right. It's, it's important. I think also it's important if, if you can get the hard version to get it so that you have access to your records at all, at all times.

But so now looking at this, what we call the published literature, and what we mean by that is the, the medical literature, which is not Dr. Google. Right? I know you make that distinction a lot, Alan, and I think it's important, you know, for our listeners to understand that just typing into the Google search bar is not what we're talking about here.

We're talking about going directly to these specific specialty organizations, or even to like a PubMed or some of these other places, right? To do our searching.

Alan Feren, M.D.: Absolutely. Those are the places to start. And the most simple place to really start is like clevelandclinic.org or mayoclinic.org 'cause these are very credible, well-recognized organizations.

So that's, those are good places to start, particularly if you're not really comfortable with doing research. You know, going to the NIH or PubMed looking at articles, it's very difficult for the lay person to understand what that is. So I, I think this, the Mayo Clinic sites and the Cleveland Clinic sites and other specialty sites are, have portions that are written specifically for the layperson.

Jordan Shields: And to be fair to Google, sometimes when you do a Google search, you know, it will say, here's this article and it will say Cleveland Clinic, whatever. So yeah, in order to simplify things to myself, I'll go to Google, but I'm looking for the credible sites within it. And, and those are the ones that Alan mentioned, cuz I can't remember Cleveland Clinic, well Alan remembers, Cleveland Clinic cuz he, you know, interned there and, and I know what it is, but many people, I can't think of these things. Google will least help say, these, these are, these are, these, are they.

Joyce Griggs: That's, I think that's really important. Then, then you look for those credible sites, and it may not be the first site that pops up because that might be a paid ad from somebody who has a, you know, an ax to grind or a dog in the fight.

Jordan Shields: You may have to go to the bottom of page one or the start of page two, but yeah, but look for something credible and when you pop it up and you see a peer review article with five doctors' names, and chances are it's, it's credible.

Joyce Griggs: If it comes from Mayo Clinic, we'll just reinforce that, Mayo Clinic or Cleveland Clinic, these are two credible places that have a lot of great information that's distilled for the layperson so that we could just understand it, as well as having access to, you know, what we call the peer reviewed literature, which is that scientific literature that if you have that level of understanding, you can dig into that as well.

So what are we looking for? You know, we do these searches. What, what are the things that we're looking for when we're doing our homework?

Alan Feren, M.D.: We're looking for things that substantiate what it was that you had done and what was the outcome. So it's very important to, to, to look for peer reviewed literature, if that's what you're gonna do. I think also the looking at the Mayo Clinic and the Cleveland Clinic areas to see if it's something that's pretty standard in the, in the medical community.

Joyce Griggs: Right. So there's all these different specialty organizations too, right? They publish what are known as guidelines, and these are the guidelines that every doctor. Well, really, and I mean at least in America, for these American associations are using to base, you know, their their care plan for you. So we wanna look to see if it's in the guidelines a lot of times too. Isn't that right? Or is that just one place to look?

Alan Feren, M.D.: I think it is one of the places to look. Yeah. Yeah. So the AMA obviously has good information for you. American Cancer Society, the American Academy of Pediatrics, the associations that look at immunization practices. So all these, there, it really depends upon what you are looking for. What is, what is your particular case?

Jordan Shields: But, but picture it this way, the when, whenever you're doing research, the purpose of research so you can finally write something about it. Humanize the people in the insurance companies, which I know is difficult to do cause they all seem some bureaucratic, monolithic thing.

But the person that's reviewing your claim is a human being who may or may not have experience, considerable or otherwise, and all they're really doing is pushing back to you and say, I don't get it. Explain it to me. Okay. Once we've gone through, you made a mistake on social security number. You didn't get this information about prior authorization. Okay. That technical administrative stuff. You've gotten it outta the way. Now you're dealing with what Alan's kind of referring to now, which is medical necessity and why I need this and why this has to happen. It's a conversation. It's a dialogue. It doesn't need to be, listen stupid, this is what's going on.

No, it's like, okay, this is why. This is what, this is how, this is what I'm saying. This is what I need. This is when I need it. Really basic journalistic who, what, why, where, when, how. And so on. And that, they'll respond to that because it's very plain, short. And then they look at it and go, okay.

And then at least they have some basis for saying, okay, now that I've seen this, it's still denied because... and the, because of what you can then take your appeal to the next step.

Joyce Griggs: Mm-hmm. So I think that —

Alan Feren, M.D.: So it's important really not to be adversarial. I think that's the understatement. And that your responses need, need not to be aggressive, but it's really, how can you help me, as opposed to, you didn't do this.

Joyce Griggs: Mm-hmm. Right. No, I think that's great. So stick to the facts, make it very factual. Keep it short. Edit out our emotions about the situation. If you wanna write an angry letter to the insurance company for a private way of like getting it out, like write it down and then rip it up and throw it away. Get it outta your system. But don't put that in your appeal letter.

Alan Feren, M.D.: Right.

Jordan Shields: Well, the other thing with it too is, you know, have somebody else take a look at it because, you know, some people write, I mean, I write tons of letters. Some people write letters very well. Some people have not written a letter in a long time.

When my wife's, when my wife sends a long email or a letter to somebody, it's not her, her, you know, best thing. So she said, take a look at this, tell me what you think, and then I edit this and cut this and so on.

The other thing, and Alan and I were talking about a client of mine that we helped finally get something resolved. It took him a year of denials and reversals and so on, but he said, okay, here's the letter I'm sending. It went all over the map and my, both of our first responses said, well, this is great. This is really good background information. However, your letter needs to be this. And not this big because you need make a clear opening statement. Here's what I want, here's what I need, here's what I'm enclosing. The other material can be attachments. So we basically schooled him in how to write an effective letter. A lot of people can do that. It just so happens that's what we do pretty much for a living, but it needs to be clear. It needs to be short, and it needs to have a call to action on their part. So you need to tell them, this is what I need from you, and this is when I need it.

You can assume nothing. Oh, well, I'll send 'em a letter and they'll get it from there. No, they won't. If they even read it. If I'm looking at a five-page letter that comes in the mail and I've got twenty 1-page letters, which letters do you think I'm gonna read first? That five-page letter gets stuck back on the stack as it should be because either you can't make a case or I need to get my head around it and I need some breathing room to do that. So short, simple, clear with a call to action.

Joyce Griggs: Okay, so now, okay, so we've done all our homework. Now we're writing and we're, and you're saying, start with your call to action, which would say something like, What, for example?

Alan Feren, M.D.: It's pretty simple. It's this has been denied and this is why I feel it has not been denied correctly and indicate that for the, the following reasons, based upon whatever the research is, which will be an attachment and attached to the, the document and be very clear as to if there are quotes from a, a, a given specialist another physician, include all that information.

But it needs to be orderly, thoughtful, needs to be concise.

Jordan Shields: And bullet points help.

Alan Feren, M.D.: Very brief.

Jordan Shields: Dear Dr. Feren, I respectfully request your reconsideration of the denial of my claim dated for this procedure on this date of service with this provider, all in the first sentence. Now I'm looking at it going, I got it. I know where I'm going. I know what I'm doing and all that. I disagree with your conclusion for the following reasons. 1, 2, 3, 4, 5. Thank you very much. I will follow up with you shortly. Let me know if there's somebody else I should be send sending this to. Appreciate your attention. Sincerely, Jordan Shields.

Bang. Done. One page. One page only unless there are attachments. I have attached this for the latest guidelines and all that for your consideration. See second attachment.

Joyce Griggs: That's awesome. That's, that's really super helpful. Now would the person in my doctor's office that deals with insurance be able to help me with this letter? Is that something that you ever see happen or is it like, could they look at it for me? Or is that a rare?

Jordan Shields: They could look at it. Sure. Just, I mean, if you're only asking somebody for a minute to scan it to make sure he got all your stuff together and you've stated things properly. Absolutely.

If you ask them to write the letter. No. Not gonna happen. And even if it does, I mean they could be the most well-meaning people in the world. They're busy, they got a lot of patients, and so it'll take weeks even when we've asked doctors to write a letter, I say, doctor, I'm gonna write the letter for you based on the information that I have available to me. And just take a look at it and you can go ahead and modify it. I think I'm doing 'em a favor. Some of them get upset with me saying, you know, you're not a doctor. You can't write. I said, I'm an insurance person. I'm just writing the letter to the insurance company. I'm not writing it to, you know, the Journal of Medical Affairs.

Joyce Griggs: Right.

Jordan Shields: So let me write it for you and all that. And then, and most of 'em are, you know, they're finally receptive going. Yeah, I can do that cuz it takes 'em 30 seconds. It takes them three weeks, but it takes 'em 30 seconds.

Alan Feren, M.D.: Yeah. Just recall though that the insurance person is not a medical person.

They just really understand coding and things like the administrative decisions that health insurance companies make. So they're really not a good person to review your letter. A, a better person to review your letter is someone who is medically literate. And it can be, you know, a, a friend who is in the healthcare field. But I think an advocate is very helpful in this situation. A medical advocate. We can review those kinds of letters. In fact, the one that Jordan was referring to, I had to totally rewrite because it was just all over the place and it was not written in a way that would be acceptable or understandable by an insurance company.

Jordan Shields: He's referring to the client's letter, not to my letter. Just so we're clear.

Alan Feren, M.D.: Actually, I didn't see your letter, but that's okay.

Jordan Shields: Mine was a lot shorter. I mean, Alan's absolutely right, but there's a, there's a middle point. So I am medically literate, but not nearly as medically literate as Alan, so if you have a good advocate on your side, but Alan's quite right that when I'm writing the letter, I'm looking at it from an advocacy and administrative position, which is gonna be 75%, if not more of it. I don't get into a whole lot of medical speak, and when I'm asking the doctor to write the letter, I said, just make sure I have these two sentences correct about the medical necessity for this and why you recommended that and, and that's it. I'm not trying to put words in their mouth about what's necessary here, cuz I'm also not trying to build a medical case. I'm not trying to send this person to a surgical center and have doctors be talking amongst themselves and trying to get them to talk to someone in plain language. Someone who's also not medically literate. And make sure they understand what we're looking for. I just wanna make sure I've got the phrasing correctly and I haven't misused any medical terms. So that we're clear because what Alan's now talking about, when you get really deep into medical advocacy is where you've got a real mess of a situation where the carrier and the doctor and everyone's required to unpack it to see if they can get it covered. That's a whole different level of medical appeal and medical denial, an important one. But 90% of what we're talking about are, can be accomplished with what we're, what we're saying here. Just so we're clear.

Joyce Griggs: No, those are great, great, great points. Know what, know what you're dealing with. For most medical appeals, we need to follow the guidelines that you guys have just outlined.

I just wanna reiterate something that Alan you said earlier too, is like, we need to keep records, right, of everything.

So we wanna keep the records of all of our procedures, the medicines, the second opinions, the prior authorizations, everything. Keep a record, dates, times, who we spoke to. This is like critically, this is critically important, right? Because we may need to use this material later.

Alan Feren, M.D.: Yeah, I may be old fashioned, but I still have manila folders.

So

Jordan Shields: do I.

Alan Feren, M.D.: And I, and, and in addition to folders that I keep on my computer, I have, I have hard copies of everything. And it just absolutely important to, to know who you spoke to, when you spoke to them. What was the conversation? What was said? What was the determination? When is the person gonna get back to you? Phone numbers. When you are struggling with someone, you can kindly ask to speak to their supervisor. If there's something, if you see that you're not getting anywhere with the person with whom you're speaking to at the health plan. But I think keeping a separate file just is just absolutely important.

And that includes after you have written your letter and you send it.

Joyce Griggs: Yeah.

Alan Feren, M.D.: That goes into a hard copy goes into your, your file. If you fax it, make sure you keep a record of the, the fax that was sent. You can print out your report to show that it was absolutely sent and if you mail it, make sure you use either return receipt required, certified mail.

If you are in a hurry and have the finances, send it next day today via UPS, FedEx. Keep the tracking number, go online, see if, if they've received it. So you have all this information so that when you are in touch with the, the insurance company, say, we didn't get it. Well, you have the information that supports well, gee, it was sent. It was signed for, it was received, everything.

Jordan Shields: The other thing with, related to, regarding to the records is make sure someone else in your immediate sphere of whatever knows where the file is, something happens to you or you get sick, you're on medication, you can't remember, and all that. Another person should know where the file is.

You're responsible for it, but whatever. The other thing I, I wanna mention along these lines, we, we've overlooked it is that carriers have a a default mechanism, and they'll, and they'll put it even in the benefit statement or when you write to them, they'll send you this thing. They'll say, we have a grievance procedure.

Well, you're not aggrieved. You are arguing about whether this was denied properly. The grievance procedure, and, and I know that this is true in California, I don't know about other states, but there is a state law that says you have to give somebody 30 years to file a grievance, 30 days to file a grievance.

Alan Feren, M.D.: It takes 30 years, but —

Jordan Shields: Yeah, well, it will take 30 years, but you got 30 days to file it and but here's the problem. The carrier will say, we have a grievance procedure and people, and I, I get people coming to me, I filed this grievance and they said everything was fine. The grievance process is to accuse the carrier of not following their own guidelines or getting you things in a timely manner, and all that.

Carriers are rarely guilty of that. And this goes back to my original point where they're trying to get this stuff off their desk. If they stamp it denied and shoot it back to you in a timely manner, they have complied with their requirements, even though they may have barely read your file. And then they have to respond in a certain period of time when you file a medical appeal.

And again, that's why short, concise, and so on. So when they hit you with the, well, you can file a grievance, don't even bother.

Joyce Griggs: Okay.

Jordan Shields: Don't even bother because that's not your situation. You are not saying that they burned you by, you know, playing around with procedures. You're just saying, I'm trying to file this appeal.

Alan Feren, M.D.: That's a good lead in though, Joyce, to what are your options when you've gone through their appeal process?

Joyce Griggs: Well, hang on just a second before we go there, Alan, I just wanna make that clear for the audience. So what we're saying is that if you get a denial. You would then file an appeal, which is a different kind of process. You're not, you do not wanna go into grievance if they try to push you that way, you wanna say, No, no. That I'm not, you know

Jordan Shields: They're required, they're required to state that, and the benefit statement will have the grievance process attached to it, because at least in California, it's state law. It's not, they're really trying to push you off. They have to tell you that, but that's not what you're doing, so ignore it. And move on to the appeal process. Correct.

Joyce Griggs: Okay, great.

Alan Feren, M.D.: And there are different levels of appeal. There's the first level, and then there's a, a second, second level of appeal, and that is by the health plan their final determination.

So your next step is, an independent medical review, you, you are able to request that. Health plans will give you instructions on how to file an independent medical review.

Joyce Griggs: Okay.

Jordan Shields: Just so we're clear first level of appeal is the letter that we were talking about, Alan's now talking about the second level of appeal after they pushed back and said, we still don't see it.

There we go. Sorry.

Alan Feren, M.D.: And the independent medical review is very important, and it's really what, what we, what we were pushed to for the client that Jordan had mentioned with the daughter that had a, a behavioral health issue. So with the independent medical review, that is the final arbiter. In other words, they are able to overturn the, the second level of appeal that a health plan has.

So don't give up after your second level of appeal is not overturned.

Joyce Griggs: Okay, so I send my letter of appeal and they write back to me and say, sorry, it's still denied. Then I would go on to an independent, I would request an independent medical review as my next step.

Jordan Shields: Not necessarily.

Joyce Griggs: Okay.

Jordan Shields: I mean, it depends on what they've said. And maybe they've given you an indication, so, well, if you can give us this, then we might be, you know, willing to go ahead and do it.

Joyce Griggs: Okay.

Jordan Shields: Again, don't panic. Take a deep breath. What are they saying? What are they asking? What do I need to do? You don't wanna start bringing in the big guns until it's absolutely necessary, cuz they may just be arguing about some, we need, we need additional information from the doctor that says this.

We need additional information from the hospital. We haven't even received the hospital chart. It's not that we're denying your claim, we're just telling you we can't pay this claim based on the lack of information from the hospital. We don't even know you were there. You know, that kind of thing. So there could be three or four, you know, pieces of conversation before we get into this. The, the case Alan mentioned, this went on for a year and we had to go through all these phases before we finally got to, you know what, you, the carrier, are arguing with this facility and one of you is wrong. And it turned out the carrier was wrong. But we couldn't do that on day one.

We had to get through all the crap. And not once did we file a grievance, because the carrier never did anything wrong in all that time. They just kept pushing back going, we don't see it. We don't get it. Our inde—, our internal review person said. Well, yeah, well, that's why we need an external review person because your internal review person, they can't help it, but they automatically have a bias, let's find a way to deny this claim. It's a hundred thousand dollars. I don't blame him, but that doesn't make him right. But it does make it longer.

Joyce Griggs: Mm-hmm. Mm-hmm.

Okay, so this is good. So I may put in my appeal letter and they might write back and say, it's still denied because we still need more information.

Jordan Shields: They may say that they may not, which means when you call them and ask them, but then they will tell you on the phone, we still need more information. So it isn't always on the benefit. Cause that takes time.

Joyce Griggs: Okay. So they might just deny it. And what they really need is more information. So if I get another denial, give them a phone call and say, Hey, can you tell me why or is there something.

Jordan Shields: You or your advocate make the phone call. Yeah, what's going on with us now? Then they look it up. Cuz now they got you on the phone and well it says here, we're still missing records from blah, blah, blah, blah. Why didn't you say so? Cause we don't have that kind of time. And the computer only has a footnote for it denied.

So again, that's why you don't want to bang your head against the wall. They're following a procedure, whether the procedure's good or not, or whether it should be better or not, we don't need to argue all that. The bottom line is they're at least throwing it out to you and saying, you need to follow. You need to take another step. You need to take another step. That's what they're telling you. It's a challenge. It's fun, it's exciting, or it's frustrating, but it, it is an invitation to continue the dialog. You wanna really ratchet it down. An invitation.

Alan Feren, M.D.: So it's a good point I think, Joyce, that Jordan makes, which is early on try to find out what is the, what does the health plan really need, right? So if you get that early rather than at the very end, you're gonna save yourself some time.

Joyce Griggs: Okay, so with everything you've said, so then it comes down to your four, your four don'ts, which I think are kind of the heart of it. I like the way you put it. You know, don't accept the denial as final, because as you said, Jordan, they only have one button that says denied. They don't say why, and there might be a a why behind that, that you can take care of.

Jordan Shields: Right.

Joyce Griggs: Don't get frustrated and upset and paralyzed because maybe you can just write a simple, straightforward letter or make a phone call and say, Hey, what's missing?

Jordan Shields: Right. We can get frustrated and angry, but don't get paralyzed. Just get over it and get on with it.

Joyce Griggs: Get on with it, get over it, and get on with it.

And make sure you've kind of reviewed everything before you get in, in line with your healthcare professional. Right? Your healthcare professional could be helpful, but you need to understand things a little bit yourself before you p ull them into the process.

Jordan Shields: Right.

Alan Feren, M.D.: Yeah.

Jordan Shields: Yeah. They're not really your first line of defense.

I mean, they, and they may not even be, it may not even be necessary to involve them at all. Which is good cuz they get busy and it will take time. I, we rarely end up calling the doctor's office for anything. Unless it's absolutely necessary.

Joyce Griggs: And ask for help, right, from, from the right people. A patient advocate, HR benefits managers. It depends on how big your company is, the insurance broker, right? Who else?

Jordan Shields: I think it's important that they look like us. Either they got gray hair and glasses or they look like Angry Santa, one or the other, but clearly we have a lot of experience between us. So if they're talking to some 23 year old rookie is like, eh, that's not a good idea.

Joyce Griggs: So yeah, you need somebody with experience. Right, because there's a, a lot of it is just like been through it before and I mean, I think it's amazing what you're saying is they just write denied, but maybe they just need a piece of information. I mean, I think I would, I didn't realize that myself.

Jordan Shields: That's 45 years of collective wisdom right there. See, look at all the trouble I save you in just 10 seconds. It's unbelievable.

Alan Feren, M.D.: Yeah. Just remember the people that are doing these initial levels of denial, they're people really with not a lot of medical knowledge and experience. They're just using guidelines. It's just like when you call for tech support. They have people who are rifling through, you know, a manual and they find what it, what the manual says, but then you need to speak to their supervisor. So this is the same.

Jordan Shields: Unless you really did, to get to plug in your computer, in which case nobody can help you.

Joyce Griggs: Right.

Alan Feren, M.D.: Exactly.

Right.

Joyce Griggs: Right. No, this is really great. So anything to say, anything that we haven't touched on or anything to say in summary, I think this was quite a great conversation.

Alan Feren, M.D.: Well, there are other organizations that can help you. Patient advocate association is very good. United States of Healthcare, I understand, has some good resources.

Jordan Shields: We've heard rumors. We've heard rumors.

Alan Feren, M.D.: We'll certainly want, certainly want to use them. There's the Greater National Advocates if you're looking for an advocate in your neck of the woods or even someone outside that has national capabilities.

So, you know, use, use the resources. Be be resourceful to look for resources to help you in whatever it is that you're trying to defend and promote.

Joyce Griggs: Hmm. No, that's great. Really appreciate it. As always, it's so amazing to talk with both of you Jordan Shields and Alan Feren, and thank you so much for all of your expertise.

Alan Feren, M.D.: Thank you, Joyce.

Jordan Shields: You too.

Joyce Griggs: Thank you so much for watching, and before you go, please check out our blog. There's many detailed blog posts for you to check out there on this topic and others that will be important to you as you navigate through your healthcare. And if you haven't already, please subscribe because you will get on a regular basis in your inbox a knowledgeable friend who's gonna make it easier and simpler for you to deal with all of your healthcare needs. Also we have a resources page that's full of free and very important resources that you can take advantage of. So check out the blog, subscribe to our content, and check out the free resources page. Thanks again for watching. I'm Joyce Griggs for United States of Healthcare.