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The Challenges in Proving a Medical Exception.

Estates can be in shambles for years over medical bills, especially when the bills start to surpass an average yearly household income and coverage requires proving an exception to standard procedures. For insurance to cover a specific care plan, it must usually not be experimental and be within network. The battle behind the bill can often drag out to a standstill. Some clients die before seeing their medical care covered, and others wait years to be approved.

In one case in this author's experience, a woman was suffering from Stage 4 cancer for over four years. She went to the same hospital and saw the same doctors throughout her illness; the hospital was close to her home, and she had gone there for three years without an issue. But in 2016, state insurance coverage ceased covering any additional treatments, visits, or services rendered at that hospital, and her insurance company's contract with the hospital ended. The hospital would no longer accept her insurance, and her insurance would not cover her visits, period. Even as more bills came in, she had to continue to go to that hospital for outpatient care and any hope of survival. The stress of the situation was debilitating to her and her family, and her health started to deteriorate rapidly.

Navigating this system requires an understanding of how health insurance carriers, healthcare providers, and the insured fit into the process of getting care covered. The insured is responsible for all medical bills and has the burden of making providers and insurance companies negotiate to cover care. Proving extenuating circumstances so that needed care from an out-of-network provider is covered requires building a case using medical records, physician recommendations, and more. When an individual has someone to help advocate a position, insurance companies and healthcare providers are forced to see the person behind the numbers.

Medical insurance advocates have the ability to build cases proving exceptions and know who to call to ensure that providers and insurance companies act ethically. In the case outlined above, politicians were called to agitate for coverage on behalf of the woman. The case was negotiated, but after six months, the state department of insurance was still unable to help her, and the case had to be submitted to the attorney general.

After a four-year health battle, the woman died. Due to the actions of her medical advocate, however, her case was settled approximately three weeks after she passed, and the hospital was paid in full (nearly $1 million in total billing).

When the needs of the insured are ignored, time is wasted, life gets harder, and illnesses progress. Another woman waited over 20 years for the approval of what was considered "experimental treatment" (specifically, brain surgery) for an illness that was labelled as "treatment resistant." To get approval for the experimental treatment, she first had to follow the standard treatments for her illnesses. She tried over 30 different medications, had a hysterectomy, and underwent hormone replacement therapy, all with no results. Multiple doctors called for approval of the brain surgery. Family members wrote letters that detailed their hardships in dealing with the prolonged denial of a procedure that became less "experimental" and more "medically necessary." Finally, a medical insurance advocate organized the medical records of the insured to prove the medical need for care, and the woman was finally able to regain her life.

The relief that comes from bills being paid or procedures approved is a blessing to patients, family, and friends. The advocacy and negotiation that facilitates a payment for medical costs alleviates stress and saves personal assets. A patient's financial portfolio does not have to be held down by medical bills, and no one should have to die before an insurance company acts. Medical bills can be negotiated and resolved, and coverage for medical care is possible when the rights of patients are advocated.

Adria Goldman Gross, FIPC, is CEO and founder of MedWise Insurance Advocacy, Monroe, N.Y.
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Title Annotation:NEWS & VIEWS: Practice Development
Author:Gross, Adria Goldman
Publication:The CPA Journal
Geographic Code:1USA
Date:Aug 1, 2019
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