You can also reach out to the Patient Advocate Foundation, Davenport-Ennis suggests. "We do not charge for services and have professionals who work all day every day helping with just such matters," she says.Appeals can be life-and-death matters. The most important thing to pay attention to during an appeal is the status of the disease. If the status changes, realize you can reach out for professional help.
Round two and beyond
"If you've been denied again, this is when we recommend you get third-party help," Davenport-Ennis says. "We've been doing this every day for 11 years and know what the companies are looking for; and they don't care about any information that doesn't show where their decision was wrong."
If you reach level three, the insurance company will normally assemble a three-party panel of doctors to assess the case. Make certain the doctors on your appeal are specialists in your area of treatment. If they're not, appeal that. You want to make certain they understand the case. You don't want a podiatrist judging pediatric cancer treatment, as Davenport-Ennis points out.
If your plan is with a small company and is not guided by the federal law ERISA (Employee Retirement Income Security Act), you'll contact your state insurance commissioner. If yours is an ERISA-guided or self-funded plan, your recourse is the Department of Labor. The Employee Benefits Security Administration (EBSA) at the U.S. Department of Labor is the agency that enforces ERISA's provisions. Either call EBSA at (866) 444-3272 or use its Web site to find an EBSA regional office.
Check if you can be present to make a presentation of case. If the answer is yes, be aware that you may only be on the phone. Work with your attorney to make sure you really hit the facts, almost in bullet form, because you're battling points of contract. If a doctor is allowed to be on the phone call with you, make sure that he or she mentions that if the case goes to a court of law they will be able to testify that within this community of practitioners the vast majority use the treatment as standard practice.
The next round is external appeals.
If the case goes to court, the judge will allow your physician to testify as to the prevalence of the denied benefit. Davenport-Ennis assures if that is the case you are very likely to win an external appeal.
Whether you find yourself nearing the end or at the beginning of the process, don't get discouraged. According to Davenport-Ennis, "Frequently you will have to go through more than one appeal to get that covered. Those who come to our organization have a 98 percent success rate."