Hi Jen: Thanks for posting this article! A little bit of knowledge and a lot of organization can make all the difference in a successful insurance appeal. I would chime in that keeping detailed notes of phone calls (including times of phone calls, the names of everyone you speak with, and reference numbers for the call), following up in writing always, and making sure that you meet every deadline laid out in your policy can make or break the claim. As a former in-the-trenches attorney for insurance carriers and as a current advocate who handles insurance appeals and grievances, the paper trail is critical.
For private insurance, make sure to ask for a full copy of the policy. It should set forth the rights and responsibilities of an insured. If you have questions about why a claim was denied, you may wish to request a complete copy of the claim diary and notes from the adjusters who handled your file. This may give a lot of insight into the denial.
Also, your state's laws may have additional protections or requirements they have if you want to pursue the claim. For example, in Florida, our laws have notice requirements before we file lawsuits for insurer violations.
Finally, for caregivers who are handling insurance claims and appeals for someone else, it is crucial that you have the proper paperwork to speak on behalf of the insured person (for example, a Durable Power of Attorney that specifically lays out powers like "preparing, signing, filing, and appealing" Medicaid or insurance claims).
I'd love to hear input from other caregivers who have had to appeal an insurance claim for someone else. Was the denial reversed? What did you wish you knew, looking back? My post is running long, but I'd be happy to share a few stories as well.
Amanda Singleton All posts are intended to convey general information only and not to provide legal advice or opinions. The posting and viewing of the information in this community should not be construed as, and should not be relied upon for, legal or tax advice in any particular circumstance or fact situation. The information presented may not reflect the most current legal developments. An attorney should be contacted for advice on specific legal issues. Nothing written in this community is intended to create an attorney‑client relationship. An attorney-client relationship may only be established through direct attorney‑to‑client communication that is confirmed by the execution of an engagement agreement.
Since this AARP article is directed to Caregivers, It might be an excellent place to stress and describe the importance of having a healthcare directive or healthcare POA or an AUTHORIZED Representative under Medicare. The later is assigned differently than a health care directive or healthcare POA. Since Medicare now has a good individual personal site under MyMedicare, assigning an AUTHORIZED Representative by a person on Medicare is relatively simple and can be done sooner than later - meaning don't wait for necessity.
With privacy issues paramount in today's society, it will serve people well to go ahead and assign a representative for themselves, after asking the designated person, of course, because it is not easy if for some reason the covered person cannot verbally give permission to speak to another about any claims problem, no matter which type of coverage and specifically when there is a caregiver involved.