I was scheduled for a third spinal surgery, which got cancelled one day before because the insurance company denied it.
My surgeon is making an appeal, which is dragging on. I received paperwork from both my insurer (Excellus) and Medicare about appeals. Never having gone through the process I was hoping I could get advice from those who have.
Excellus offers an appeal basically asking for my reasons for appealing and any supporting evidence.
Medicare uses C2C Solutions. I have a right to a hearing with an Administrative Law Judge (ALJ) or Attorney Adjudicator (AA). Can be done over the phone.
Is there a reason to prefer one over the other? Should I do both? Does doing one conflict with the other? What’s the difference between an ALJ or AA?
What is the best evidence? How should it be presented? What works?
The paperwork informed me of phone numbers for the State insurance department and for Excellus and Medicare. I’ll be calling them, but I expect they can only say “these are your rights and options” stuff I already know.
What about switching to a new insurance provider? The enrollment period for ACA marketplace insurance is coming up on Nov 1st. Maybe you could find another provider who would be more likely to approve the surgery.
That’s always a possibility. But any new insurance wouldn’t go into effect until 2027, and then the process would have to start all over. And there’s no way of knowing in advance who to go with that would give approval.
If a physician requests the expedited reconsideration, plans are required to expedite the request.
ETA:
Once the plan receives the request, it must make its decision and notify the enrollee of its decision as quickly as the enrollee’s health requires, but no later than 72 hours for expedited pre-service benefit or Part B drug requests, 30 calendar days for standard pre-service requests, 7 calendar days for standard Part B drug requests, or 60 calendar days for payment requests.
I know it refers to “pre-service requests,” but the text comes under the heading of: “How a Health Plan Processes Reconsideration Requests,” and … since you haven’t had the recommended/needed procedure … [NB: maybe that’s obvious, but the wording had me a bit uneasy…]
I think the best way to get an appeal pushed thru swiftly is thru your doctor. The denial stated “not enough info” or somesuch to make a decision, so your doctor needs to follow-thru and provide the necessary documentation that justifies the surgery. Ride your doctor about this, and in parallel, call the insurance and clarify what info is specifically needed, and then make sure your doctor knows this. The “evidence” the insurance is looking for is not from you, but from your doctor - they need to get on the case as a priority, and the way to ensure that is happening is to bug the doctor.
Going thru an external review board (external to your insurance and doctor) is likely going to take a while, and may be a “last resort” type of thing.
Is your Excellus insurance the usual sort of “Medicare Gap” insurance, designed to help pay the 20% that Medicare does not cover? If so, did both deny the surgery? Since they both contribute, they both need to be dealt with. I would start with Medicare first, because as long as they deny the operation, your gap insurance isn’t even consulted. If this isn’t your insurance arrangement, never mind.
Anyway, if and when you try the Medicare appeal, I would in general think an ALJ better than an AA, unless they have exactly the same qualifications. Full disclosure, my father was an ALJ for worker’s comp for 20 years, and I was always impressed with how rigorous they were; his decisions were subject to appeal to state court. It might be worthwhile to find out if Medicare ALJ decisions can be further appealed.
Good luck. The doctor’s office may not be well-staffed in support people able to write such appeals, which may be why it is taking them a long time.
Remember there are two types of Medicare plans: the Supplements (like F and G) and Medicare Advantage. The supplements automatically approve anything Medicare approves. The Medicare Advantage plans are the ones usually denying coverage–that is basically how they appear to be offering better value–because they deny a lot of treatments. So you want to choose a Supplement plan.
We have some experts on Medicare plans here; perhaps they will comment.
I’m asking about level 3 appeals. The format is in the boilerplate I’ve already received. I’m hoping that somebody who has been through the process will tell me their experiences.