How To Appeal An Insurance Denial For Spine Surgery

Category: Spine Surgery | Author: Stefano Sinicropi | Date: December 5, 2017

Spine Surgery Insurance

Spine surgery is an intricate and sometimes difficult procedure, and oftentimes this equates to a large medical bill. Thankfully, if you have insurance, much of the cost of your operation may be covered by your insurance company. Many patients call their insurer or inform them about an upcoming procedure to ensure they are covered so they aren’t stuck with a huge bill. But what happens if your insurance company says you aren’t covered for a procedure?

If your insurance denies your claim, it’s not the end of the road. You have the right to appeal the denial and to work towards a solution that fits your situation. Through our own experience and by talking with medical professionals and other patients, we’ve learned some things you can do to help improve your chance of being approved for spine surgery by your insurance company. Below, we share some tips for getting your surgical appeal granted.

Work With Your Spine Surgeon

In many cases, insurance tries to deny the coverage by saying that the operation is elective, not necessary. A spine surgeon can often better convey how and why the operation is necessary for your health. However, don’t just walk into your doctor’s office with your insurer on the line. Talk to your surgeon to see if they would be willing to communicate with your insurance company as they see fit, either over the phone, through email or with a letter.

Research and Understand Your Insurance Company’s Appeal’s Process

Under the Affordable Care Act, every insurance provider is required to have an appeals process in place. If you’ve been denied, call the insurance company and ask them about their appeals process and what you need to do to have your case reconsidered. Once they outline the necessary steps, get to work on your appeal.

Be Polite and Build Rapport With Your Contact At The Insurance Company

Imagine you worked at the insurance company and you took calls all day from individuals with questions or concerns. Who are you going to go the extra mile for? The person who calls you up and starts screaming at you about their denial, despite the fact that you personally had nothing to do with the denial, or the person who is polite and courteous and understands that you are only the messenger? We’re much more likely to help find solutions for people who are polite and kind than those that yell and demean. It’s understandable that you are upset about your denial, but yelling at the agent on the phone will only hurt your chances of getting your surgery approved.

Evidence, Evidence, Evidence

Finally, when you’re filing your appeal, give as much evidence as to why you need this surgery as possible. Another common reason for denial is because your pain may not seem like that big of a deal, which isn’t always easy to decipher from a couple of pieces of paper. Have your complete medical history handy, and outline any and all conditions and treatments related to your spine. It may even help to write a personalized statement about how your spine pain has affected your life or your ability to work. When the insurance agent starts humanizing the problem instead of just seeing it as claim number 493, you’re much more likely to win an appeal.

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