You'll find hundreds of files on cleft lip, cleft palate here on widesmiles.org.

This one is about: How to Fight Insurance Companies


(c) 1998 Wide Smiles
This Document is from WideSmiles Website - www.widesmiles.org
Reprint in whole or in part, with out written permission from Wide Smiles
is prohibited. Email: widesmiles@aol.com

How to Fight Insurance Companies

I have been working with a wonderful woman to put together some great info on fighting with insurance companies for approval.. Here are the basic starting points. Her name is Sherry Gilligan and here is the first of much info to come:

It has taken me awhile to gather my thoughts and information to pass on to you. The meeting went well. I was astonished at the end result to everything. Turns out all the turmoil is truly the insurance companies way of stonewalling. I think I have figured out a way to breakdown their wall from the get go and keep families from having this happen. It will be time consuming in the beginning but will hopefully have lasting effects. We have had the experience of even having insurance companies change during a pre-authorization process. Bottom line is DOCUMENT AND DOCUMENT.

Keep all the information and notes in order and GET NAMES AND GET as much as you can IN WRITING. A lot of what we have already done was concurred by our Broker, Insurance Rep and Human Resources person to be the best way of getting things done. Unfortunately we had made some mistakes and it took us a while to discover who is key personnel and who isn't.

Here are the steps:

1) READ YOUR INSURANCE POLICY:

a) look for clauses that relate to reconstruction/cosmetic/plastic surgery. Ask your insurance BUDDY (see 2a) questions about how these procedures relate to your child's needs.

b) If you have an HMO - Verify your doctors are on the list. If not write letter(s) to request referral to your current specialist. The most heart breaking documents I have received deal with people who were forced to use doctors unfamiliar with the cleft/lip and palate procedures. Verify how many cleft cases the doctor has had. Talk to the doctor and see how he/she feels about working with cleft procedures. I found Doctors to be quite up front with whether or not they have the experience it takes to do the procedure. Get references. The information you receive can be used to convince the HMO to allow you a referral.

2) Get people to understand the cleft defects the procedure and your child's needs:

a) Create a liaison both within your Human Resources Dept and your insurance company - ALWAYS HAVE ONE SINGLE POINT OF CONTACT with both groups - your new BUDDY.

NOTE: Companies sometimes hire Brokers that have the companies best interest at heart when purchasing insurance. The Brokers are not always available to do one on one contact with you directly but will be there to help the companies contact with questions or problems you may be having.

b) Make sure your claims are always submitted through your single point of contact, BUDDY - make your provider aware of problems and always follow-up.

3) Insurance policies can change from year to year depending on your company.

a) Always check with your Human Resources contact as to changes coming up on your insurance policy each year, it could effect future claims. Your Buddy will already be updated on the challenges you have faced on your claims and will be more willing to make sure the new policy will take care of anything already pre-authorized or future claims.

NOTE: A "no loss, no gain" provision clause can be added to your policy to cover you if your new insurance carrier or changes to the policy will adversely effect your claim. Ask your Human Resources person to talk to the insurance broker about this when changes to your policy are being considered. (I am currently doing research to verify if this is a Federal/State mandate on all insurance carrier changes with pre-authorization.)

b) Make sure you pre-authorize everything that is needed by the insurance company. Get it in writing.

c) Verify all codes to meet the policy requirements for coverage. Contact your insurance BUDDY to get codes that will work if a claim is denied.

Insurance claims are processed by claim personnel who merely transfer information into the computer for processing. They have no control over denied claims. Do not attempt to make them understand the claim should not be denied. Most insurance companies have task forces or representatives assigned to follow and handle claims that are "difficult". For some reason Craniofacial i.e. Cleft Lip/Palate have become some of the worst to get processed. Your insurance BUDDY will play an active and vital role in getting your claims processed. Make sure you create a healthy relationship with them because YOU WILL NEED THEIR HELP. You must remain PRO-ACTIVE on your claim. DO NOT GIVE UP!


Wide Smiles depends on donations to continue to provide this resource for you.
Please help keep us online!

Cleft Links | Wide Smiles | Photo Gallery