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Consumers are In Charge

Terry McLeod

It's peculiar how control of important elements of our lives, and especially our health slip away from us.

blank checkIf "value" is defined as getting back your money's worth, health insurance value dwindled over the years to the point that consumers were discouraged from seeking help for mental health problems. The consumer's portion of the payment for service has grown through high deductibles, excluded treatments and medications, and other methods. The Department of Health & Human Services (HHS) is calling this "insurance company abuses".

The new rules and regulations are giving some control back to consumers by enabling them to appeal insurance company denials to pay for service. Insurance companies use both internal and external appeals processes, and according to HHS, processes will be simplified and easier for consumers to negotiate. Chasing down satisfaction and eventual payment has traditionally been a pain, and the changes sound like a very real way consumers can experience the newly enhanced value of the health system in America.

Whether decisions to deny payment for your claim come from a person inside the health plan or an independent decision maker, you have this increased control over your ability to get treatment, especially for mental health and addictions issues. I remember being denied payment for a claim years ago, and having previously negotiated the insurance company's appeals program and lost, I gave up, paid the bill and quit seeking treatment. That caused me grief as the problem got worse.

On a human level, who wants to spend the time and energy over fifty bucks to fight the entire insurance industry over a denied claim? At what point does it become worth the fight? As the dollar amounts that must be paid for treatment increase, the value of the appeal increases. The control we are gaining has tremendous value. Treatment can take a number of sessions, repeated assessments to measure improvement, and other services. If the insurance company is denying payment for treatment, that fifty bucks can grow into thousands, or tens of thousands if treatment is avoided.

OK, so you have a right to appeal…how do you do that?

Many states have offices (different names nationwide) to help consumers appeal claims denials, and states that don't have such offices have access to a pile of money ($30 Million) to help establish one. This is really good news, increasing value of time spent appealing claim denials by lowering the consumer's amount of effort to get the claim paid. These offices will share information that can help consumers convince the insurance company to pay the denied claim…and according to these new rules & regulations, the insurance company has to listen to you.

This will be a relief to anybody who has a child prone to anxiety attacks, or in the throws of a suicidal episode and an emergency visit to the hospital is needed, as well as follow up treatment. Situations like this can involve multiple care givers, and the hospital may not have a mental health department, so a referral might be needed. These complications equate to dollar signs, and when you look at your paystub and see the amount that's taken out to cover the child, you want the healthcare value in return for that payment. If it's not there, fight it.

You have friends in high places.