Policyholders can appeal denial of claims through four levels of review
posted March 1, 2010
With multiple studies indicating that an asthma drug could be beneficial in treating her son's chronic idiopathic urticaria, a rare disease characterized by the occurrence of daily or frequent welts and itching, Dr. Laura Strong was determined to get him access to this promising new treatment—despite the fact that it was not a drug normally covered by health insurance programs for treatment of CIU.
Knowing that the drug did not have Food and Drug Administration approval for treatments other than asthma, Dr. Strong, who maintains family medical coverage through the AVMA Group Health and Life Insurance Trust, was not surprised when the initial response was a denial of coverage. She was surprised three weeks later, however, when she was notified that coverage for the drug was approved.
In fact, Dr. Strong had been fully prepared to exhaust all four levels of review available to GHLIT policyholders.
"When you have a sick child, you're hoping not to have to go through all that extra angst," Dr. Strong said. "I really felt like I had the GHLIT to help me facilitate whatever needed to happen."
For Dr. Strong, it wasn't just the scope of GHLIT's review process that made her appreciate the coverage she and her family have had for more than 20 years, it was also the efficiency with which a resolution was achieved. Most of the activity took place behind the scenes, freeing her to focus on her son's health rather than deal with information requests and paperwork.
Dr. Strong's experience is not unusual. GHLIT participants often aren't aware that the first level of the review process, an internal review of a medical claim, is under way, because it is frequently initiated by the claims processing staff. A primary reason for initial coverage denials is insufficient information, and a single request to the health care provider for proper documentation is all that may be needed to approve a claim payment.
"Many times, all this is going on and the participant has no knowledge of it," said Dr. Jody Johnson, GHLIT director of member services. "It's a great demonstration of how our business partners' staffs are trained to take the offensive and seek needed information when possible."
A second level of review is necessary in some nonroutine cases. A specialist will review the claim and any supporting documentation to determine medical necessity.
GHLIT participants often aren't aware that the first level of the review process, an internal review of a medical claim, is under way, because it is frequently initiated by the claims processing staff. A primary reason for initial coverage denials is insufficient information, and a single request to the health care provider for proper documentation is all that may be needed to approve a claim payment.
If a coverage issue remains, the case goes to New York Life Insurance Co., which underwrites the GHLIT insurance program, for the third level of review. This step involves input by the GHLIT's claims administration staff as well as outside specialists to ensure that decisions are based on the most current medical knowledge and criteria for insurance coverage.
The fourth level of review is with the GHLIT trustees—fellow veterinarians who review the medical situation, coverage criteria, and prior determinations.
Though it's impossible for every claim to be approved, the GHLIT review process centers on the policyholders. It provides more channels for review than many other health insurance programs.
"The first denial doesn't mean all is lost. Talk to someone at the Trust office. A good percentage of the time, we are already looking at the denial," Dr. Johnson said. "Dr. Strong is the perfect example of what can happen if participants give the process a chance to work for them. If I was the mother of a son with serious health problems who needed to try a promising new treatment, I would be very glad to know that my health insurance provider cares enough to take a closer look."
Today, Dr. Strong's son is responding to the medication.
"I just cannot communicate how grateful my husband and I are that we have GHLIT coverage," she said. "This is a very challenging, very rare disease, and we are eternally thankful to have had this insurance throughout this ordeal. It has exceeded my expectations."
Information on GHLIT benefits is available at www.avmaghlit.org. Veterinarians and veterinary students can obtain more information—including plan details, rates, exclusions, limitations, and eligibility and renewal provisions—or find a GHLIT agent by calling the Trust office at (800) 621-6360.