Addressing a Denial of Medical Services in Oregon

Obtaining medical care in the United States today can be an emotional and frustrating experience. This can be especially true when you have insurance coverage only to find out the carrier will not pay for a medication, procedure, or other treatment that you and your doctor have determined you need. This can leave you feeling vulnerable, overwhelmed, and even worried about your well-being, particularly if you are concerned you will be forced into potentially thousands of dollars of debt to get the medical care that you and your team have determined you need. Assistance from a Portland medical malpractice lawyer with Paulson Coletti Trial Attorneys PC may help you get the resolution you deserve in your case.

Understanding Insurance

There are several types of insurance plans, and it can be hard to keep them straight and understand the benefits of each or even how they work. While this list is not exhaustive, some of the basic plan types are:

• Health Maintenance Organization (HMO): This typically limits care to medical providers who contract with the HMO. This plan frequently does not cover services outside of the contracted providers except in an emergency
• Coordinated Care Organization (CCO): CCOs like the Oregon Health Plans provide a network of providers who agree to work together for coordinated care. They work with contracted providers and may not cover services outside of the designated network
• Preferred Provider Organization (PPO): This type of health plan typically covers providers who are not contracted with the organization but will require you to pay more than you would for seeing an in-network provider. This allows flexibility in seeing the providers that you prefer while still having some of the costs covered

Insurance companies work with care providers by negotiating lower rates from the providers in exchange for them being ‘in-network’ with the company. For example, self-pay may be $100, but an insurance company may have a negotiated rate of $70.

To ensure specialist visits are medically necessary, the carrier will sometimes require referrals from a primary care physician (PCP) before they will cover the services. Additionally, some plans may require a preauthorization for services. Your provider’s office should be aware of which insurance companies require a preauthorization or referral to be reimbursed, but it is always beneficial for you to also know.

Why Your Oregon Medical Claim May Have Been Denied

There are many reasons that healthcare claims may be denied, and while some denials may be specific to your plan, like not having a preauthorization, missing a referral, or seeing an out-of-network provider, there may be other pieces of your claim that triggered the denial. According to the Patient Advocate Foundation, your insurance company may deny the claim because:

• Services are not medically necessary
• Services are no longer appropriate in a particular level of care or healthcare setting
• You are no longer eligible for the benefit
• The claim was not filed within the appropriate time frame
• The service is considered an experimental
• Medication exceeds the quantity allowed
• A brand name was prescribed, but only generics are covered
• Other medications need to be tried before the prescribed medication will be covered

Understanding the reason for denial will help you determine the next steps. Sometimes, it can be resolved by quickly calling your doctor to correct an error. If, after some quick investigation, you are unsure why your claim was denied, you may want to ask your insurance company for more information. If this is unsuccessful in determining the problem and finding a solution, you may want to begin the formal appeal process.

Starting Your Appeal Process

The first steps of your appeal process should be following the guidelines laid out for your specific plan. This can typically be found in your handbook or through your health insurance portal. If you cannot find information there, call the number on the back of your card for further guidance. The Oregon Health Authority (OHA) provides a Denial of Medical Services Appeal and Hearing Request form to gather pertinent information for the appeal. You must send this form to be received by the insurance company within 60 days of the initial denial. This timeline may differ for some plans and companies, so check your guidelines.

Some of the information that is important to your appeal request is:

• Initial denial letter
• Services that were denied
• Explain the medical need
• Indicate if an expedited hearing is necessary
• Medical records and physician notes

When you send this initial appeal request, you may also send the hearing request. It can be helpful to go ahead and request the hearing with the Oregon Health Authority because that may prevent you from having to make a second request. If you choose only to request the appeal and it does not go in your favor, you may resubmit the appeal and hearing request form to request a hearing.

Appeal

If you ask for an appeal, a nurse or physician from your CCO or plan will review the initial denial letter, the information provided in the form, and any additional records or notes that were sent over. They will use that information to determine if the decision to cover your plan should be changed. Your CCO or plan must notify you of a decision within 16 days of receiving the appeal request. A Notice of Appeal Resolution form will notify you.

Hearing

If you have already requested an appeal and the CCO or plan still chooses to deny your request, you may request a hearing. These are usually scheduled on the phone and will have several parties on the call. Those invited may include:

• CCO or plan representative
• OHA hearing representative
• Yourself and an advocate (if you choose)
• Witnesses you invite
• Administrative Law Judge

During this call, you will have the opportunity to present your documentation in support of your medical services. If your care provider is on the call, they will also have the chance to speak on your behalf. When the call ends, you will receive a ‘final order’ regarding the decision within 30 days.

Discuss Alternative Options

As part of the appeal process, you may be able to request a peer-to-peer review of your case. This is when your provider speaks directly with the medical director at the insurance company to review the information to get the services covered.

Discussing alternatives with your doctor may also be beneficial if the requested services are severely delayed or are still ultimately denied.

Get Support

Navigating anything with an insurance company can be uniquely challenging, especially when your health may be on the line. In cases like this, having a medical negligence attorney with Paulson Coletti Trial Attorneys PC may be helpful to help you advocate for your needs and hold the insurance company accountable if they are acting in bad faith and denying valid claims.