Unfortunately, we have come to learn that there is no shortage of tactics that insurers will use to deny claims. Insurers are notorious for denying claims…while boosting their bottom line. They use confusing terms, rules, and exclusions that make up a policy. They take advantage of the vulnerability of those who are sick, those who are elderly, and those are simply unable to fight back. Injustice seems to permeate the health insurance world when those who are suffering - and most in need of treatment - are routinely denied access.
Furthermore, these denials often come through strangers who are referred to as "independent medical reviewers." These reviewers make critical life and death decisions about a person's health and recovery, often dolling out treatment one day at a time. It seems that they focus more on an insurance company's "criteria" than on the clinical rationale of the patient's treatment team.
What happens during an independent medical review (IMR)? An independent medical review is supposed to be a process in which "expert independent medical professionals are selected to review specific medical decisions made by the insurance company." While this is supposed to result in an unbiased decision, it should come as no surprise that these reviewers, more often than not, support a denial of benefits. One reason why is the independent reviewers are usually anything but independent, and some even spend the better part of their work day writing opinions for insurers - in support of claim denials (and yes, they can make a healthy living doing this).
As ridiculous as it might seem, ultimately an insurance company can choose who performs your "independent" medical review. How can they get away with this? Only if your case goes to court, and your file contains sufficient evidence to convince the judge that the review doctors were biased or unqualified, will the insurance company suffer any consequences of their conduct. So what can you do to challenge unfair denials and unfair IMR practices?
First, if your claim is denied, understand that an insurance denial is not the final word. For advice on the appeal process, see our post on Everyday Health Insurance Challenges and What You Can Do To Overcome Them. Furthermore, if you feel that your "independent review" is not so independent, don't ignore this! It is possible for you to challenge your insurance company's decision, and here's how:
In most cases, pursuing an IMR is a voluntary appeal level, not something that you must participate in for your claim. In fact, oftentimes we recommend that our clients NOT submit their claim to an IMR, and here's why: many independent medical reviews are not wholly independent and are conducted by doctors who heavily rely on the insurance company's reviews to supplement their incomes. As a result, more often than not, the reviewers will uphold the denial. Additionally, if the denial is upheld on the IMR, the insurance company may be able to use that as further evidence that its denial was reasonable and that the treatment was indeed not medically necessary. In some circumstances, pursuing an IMR may be a good idea, but you need to consider both the benefits and the potential risks before you agree. And remember, one of your best resources in determining your appeal rights is your policy. Acquaint yourself with it. Read it. Know your rights!
At Kantor & Kantor, LLP, we work diligently to challenge these types of unfair practices. We spend every working day fighting on behalf of our clients so that they can access the health benefits to which they are entitled. If you have been denied benefits for the treatment of your eating disorder or other mental illness, please do not hesitate to reach out to Kantor & Kantor, LLP for a no cost consultation.
We understand, and we can help.