The appeals process
Be yourself; Everyone else is already taken.— Oscar Wilde.
If you’ve at least completed AHIP, you’ve heard of the grievance and appeals process. If you haven’t, you may not be far enough along as an agent for this blog to help you. I recommend you go to the video on our website about getting started as a Medicare Geek.
A sales manager for a certain carrier told me never to underestimate the power of the appeal process. I took that to heart and started helping members submit grievances and appeals when they are warranted. I thought I’d share this success story to bring it home:
In 2017, one of the HMO MAPDs that I represented had a hearing aid benefit– $1000 per ear! The problem: there were no providers on our island, so any provider her would be out of network. A long-time member of the plan talked to customer service at the provider and was told that if he went to Costco, he could just mail it in as a claim and it would be paid since there was no network provider. When he called me, I originally chastised him for calling customer service before me– with this carrier, CS was notoriously bad. Nevertheless, since he had documented that phone call with customer service, I told him I’d help. We completed the simple claim form and mailed it in. Within about a month, he got his reimbursement. Miracles do happen.
Then enter customer B. They did the same thing about purchasing a hearing aid at Costco. I told them it normally wouldn’t be covered but since the carrier had reimbursed customer A, we might as well give it a shot. This was fall of 2017. We completed the claim form and mailed it in.
After about six weeks, customer B’s wife called me. They had heard nothing. Could I help. I emailed agent support at the carrier. I got a volley of conflicting emails over time– I’d used the wrong claim form. It was out of network. There weren’t any diagnosis or billing codes on the claim, etc. Each time, I calmly pointed toward customer A where none of these questions has been asked. Some things I wrote in never received a response.
Eventually, I told customer B it was time to draft an appeal letter. We gathered all of the documentation. Got permission from customer A to use his story. (Without this permission, it would be at least a HIPAA violation to bring him up. ) He said, “Absolutely!” I helped the members draft a letter and we sent it all in.
45 days later they received a curt response: Since it had been more than 60 days from the original service, the appeal was denied based on timeline alone. (This meant they ignored the merits of the appeal.) This decision was final unless we wanted to appeal it to an outside government contractor called Maximus. Member B was devastated. I said, “Let’s keep going. We have nothing to lose.”
We drafted a letter to Maximus including all of the info and pointing out the absurdity that the insurance company denied it based on timing since we’d been in communication from the moment we sent the claim in– within 30 days of getting the hearing aids. Member B eventually got a letter from Maximus that Member B didn’t understand. This was the gist: It was favorable. But this didn’t mean they were for the reimbursement. It meant the 60 day thing was stupid so they were sending it back to the carrier to reconsider based on the merits. I wasn’t hopeful: Since we’d seen excuse after excuse not to appeal, we just assumed that the carrier would find another stupid reason to deny the claim.
We were wrong! About another month after that, they member got one letter saying the carrier was giving them a favorable decision on their appeal. A separate envelope in the same batch of mail had a check for over $1700! (For some reason they wouldn’t pay the tax but the member was fine to let that slide.)
Don’t give up on grievances and appeals if you have a good case. Insurers make a lot of money off of these government contracts. They don’t want too many complaints going directly to CMS or HHS. Also, consider the business smarts of this: How likely is this member to ever switch to another agent over a catchy sales presentation alone when I walked side by side with them for this long: They got the check in October 2019. (We started in November 2017!) It’s the right thing to do by people and it’s the smart thing to do for your business.
Go help some people and make some money.