What to do when "All of a Sudden" your Insurance Company Starts Denying your Claims

Posted by jonathan on 5/12/2016 to News
   What to do when
Imagine!  You are in the middle of life saving treatments for..... say, Breast / Colon/ Brain cancer.  The insurance has approved everything and, all of a sudden, they stop.

 Imagine! The only way to monitor your disease progression is via PET/CT, but insurance denies the request.  Has anyone else experienced this?  Imagine that your oncologist fought with the insurance company's  doctors  and all he got was “that you no longer meet criteria”.  Criteria?   WAIT JUST A MOMENT!!!!!. You have met the criteria all along.  I mean, you have cancer don't you?  How can criteria change in the middle of treatments?  Easy, because you are at the mercy of insurance doctors who are trained to save money over lives.  Whoops??  Is this a fair statement to make?  Am I, as a blogger,  being too harsh?.. absolutely not.  One of our patients have said: “ My oncologist called yesterday and said that my insurance will not approve a PET scan without a bone scan and a CT first.  OK.  I'll do that.  It's better than nothing and my tumor was to the bone.  I have been having PET/CT's every 4-5 months since MBC diagnosis.   My insurance fights with my oncologist most of the time. This could be why it may get more difficult to get a PET scan approved.  ASCO and the American Cancer Society are now saying - "Routine laboratory tests or imaging tests to evaluate for breast cancer recurrence are not recommended in asymptomatic patients.". CAN YOU BELIEVE THIS??? When I saw their report, I felt thrown under the bus.”

Now, lets back up for a minute and let me explain the definition of  a  Pet Scan  and Cat scan and the difference between them. 


Computed tomography and Positron Emission tomography are both nuclear medicine scans used to detect abnormalities in the different organs of the body.  They are imaging procedures that help determine appropriate diagnosis and decide necessary treatment for the impending disease. They are commonly used to detect cell abnormalities such as cancer,  brain’s unusual functioning, and regions or functions of the heart. Both procedures are comfortable and convenient for patients because they can be done in a single sitting without changing the positions. Furthermore,they are more detailed and accurate leaving no space for miscalculations than any invasive exploratory operations.
Though both are scanners, each has its own distinction from the other.
How do CT scan differ from PET scan? Which is better and more economical to use? The benefits and risks involved using both procedures will help the patient make wiser decisions in choosing the more advantageous one.
Computerized axial tomography or popularly called CT scan or CAT scan is a computer-generated x-ray that allows viewing of the internal body part. It produces cross-section and three dimension imaging of the structures of the body. Not only that, it can detect abnormal organs but it can also identify the operation or function of normal body organs. It is also used to direct an instrument inserted inside the body into its precise position or location.
Positron Emission tomography, commonly called PET scan, is an imaging test that utilizes a specifically designed camera to view the internal organs of the body. It is done by injecting a radioactive tracer intravenously through the arm. Tracer is a chemical in liquid form that emits positrons that can be identified and modified into a picture to find the problematic organs. PET scan is effectively used in tracing cancer, brain disorders and heart functions. It is also use to determine metabolism of glucose, use of oxygen, and flow of blood throughout the body. 
The advantage of PET scan over CT scan is that it can expose the metabolic changes at the cellular level of the body. It can detect developing diseases at an early stage unlike  CT scan, where detection can be a little bit late. However, the picture presented by PET scanning is not as detailed as CT scan due to the fact that the picture in PET scan only exhibits the area where the tracer is positioned.

1. PET scan uses a radioactive tracer that emits positron that can be modified to view organs that has problems, while CT scan is a computer- generated x-ray that can detect normal and abnormal organs of the body.
2. PET has advantage over CT scan because it can show metabolic changes at cellular level important for early disease detection.
3. CT scan is more detailed than PET because PET can only exhibit the areas where the tracer is located.”

Now that we know the differences between them, the key for me for a PET scan is early detection and metabolic changes during treatments.  I don't understand why they would force anyone to have more and more radiation injected into their bodies when the American Cancer Assoc. says that it might be too much radiation just to get  a Pet scan..I mean, really, what is the point of having the extreme technology of  PET scan ability, and then not use it for helping patients? Now, a lot of Doctors and Oncologists say that you can tell just as much from a CT scan as you can a Pet Scan, but again, this is subjective and depends on who you ask.  And, as you read the above information,  I feel that it should be your doctor's final decision which to use rather than the insurance company's.

We, at AJ's Wigs, encourage each and every client who comes through our doors to be proactive with not only their treatments but their insurance companies as well.  One of my clients- who works for an automobile insurance company - told me that, in his field,  (he didn't know about the medical field),  he was trained to know each and every loophole in the law.  They are trained to deny all insurance claims initially and only consider them the second time around.  He joked that it was much like the movie with John Travolta - “A Civil action” - in which a company was poisoning people in Woburn, MA.   When people sued, it was discovered in their training manual,  that the insurance company taught employees to deny all claims  the first time around in order to discourage a second attempt.  

We, at AJ's Wigs, have seen this time and time again.  Wigs are considered a Cranial Prosthetic.  A Prosthetic is defined as “a device, either external or implanted, which substitutes for, or supplements, a missing or defective part of the body.  Are wigs as important as a leg? Heart? Liver?  Perhaps not, but  having attractive hair defines our looks - when we enter a room for an interview, or meeting your in-law's for the first time, or becoming more confidant about one's self, or being a public speaker etc, etc,etc.. This is why most insurance companies cover Cranial Prosthetics. It involves the same procedure as a leg or any other prosthetic. You will need a prescription, a letter of necessity and certain medical codes that  only a  medically  certified wig salon, such as AJ's Wigs (who is considered a medical grade wig salon) can provide.  With wigs, if you have all your ducks in a row, and have checked your specific policy, then there is no denying your first claim and it should be paid almost immediately. This is where salons such as AJ's Wigs can help you collect. In one of my previous blogs, we discussed collecting insurance, but what this blog wants to stress is that insurance companies can change their minds during your cancer or hair loss journey. Unfair? Of course it is, but it is customary, if  your claim is above what they consider reasonable, for them to contest the payment amount.

After doing some research, I found the following on the internet that best describes what you should do, step by step,  if your insurance company changes your coverage mid stream..It is important to read the fine print on most insurance company's policies which may read  something like this... “Please be advised that this policy can change with no notice and is subject to change in policy procedures.” The following is put out by the NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS..Best of Luck.. Jon (AJ'S Wigs)

                                                        HEALTH INSURANCE: 
What to Do if a Health Insurance Company Denies Your Claim
A major illness or a stay in the hospital can be stressful. It's not a time you want to be worried about your insurance coverage. However, for some insurance consumers, this is when they are hit with a denial – notification their insurance company won't pay all or part of a claim or treatment. To help understand your course of action when a claim is denied, the National Association of Insurance Commissioners (NAIC) offers these tips.
Read and Understand Your Policy
It is imperative that you read your policy thoroughly to understand your rights and responsibilities. The Affordable Care Act (ACA) mandates that group health plans and health insurance issuers offering group or individual coverage must provide a Summary of Benefits and Coverage (SBC) and glossary of commonly used terms before consumers enroll in a plan and at renewal time to help consumers understand their policies. If any part of the policy is unclear to you, contact your insurance provider for additional clarification.

Your policy should indicate the procedures to follow to appeal a claims denial. There are typically two levels of appeal required: a first-level internal appeal administered by the insurance company; and a second-level external review administered by an independent third-party. Your state insurance departmentwill be able to explain the appeals process further if you have any questions.
What to Do If Your Claim is Denied
If you receive notice from your insurer that your claim was denied, make a list of questions you have about the claims denial and start gathering important documents, such as your policy, the SBC, and the denial letter. Once you are prepared, contact your insurance company. You will find contact information on the back of your insurance card and the denial notice, which will also contain instructions for appealing the denial. 
In some cases, a simple error could be why your claim was denied. Your provider's billing staff may have entered an incorrect code when your claim was filed with the insurance carrier, or your claim may have inadvertently been sent to the wrong insurance company. This type of error can usually be cleared up quickly with a single phone call. 
Keep notes of all conversations you have with company representatives. Include in your notes the name of the person with whom you speak, as well as the date and time of the conversation. Ask for the person's phone extension so you can contact them directly the next time you call. Listen carefully and make note of the answers given to you. 
What to Do If Your Insurer Continues to Deny Your Claim
If your claims denial is more complex than a simple error and your insurance provider still refuses to pay the claim, be persistent. Insurers are obligated to pay claims in a timely manner and in accordance with the wording in their policies; however, you may experience delays or more denials. 
The usual procedure for appealing a claim denial involves submitting a letter to the insurance company requesting that your claim be reconsidered and giving specific reasons why you believe your claim should be paid. When composing your letter, be as detailed as possible; explain why your procedure or medication is necessary and should be paid for under your insurance policy. With your letter, include evidence that supports your claim, such as medical records, x-rays, lab results, or a letter from your physician that explains why the treatment is medically necessary. If you or your doctor feels that the denial of your claim could be life-threatening, you can ask that your appeal be expedited. Keep a copy of everything you send to the insurance company for your records. 
The ACA requires that your insurance provider makes its decision regarding your internal appeal within the following timelines after receiving your request:
72 hours if you're appealing the denial of a claim for urgent care. 
30 days for treatment that you haven't received yet. 
60 days for treatment you have already received. 
In response to your letter, your insurance company will indicate the next steps in the process, as well as the timeframe for any additional follow-up or appeals. They may also request additional information from you and/or your medical providers.
You may contact your state insurance department for assistance appealing your claim at any time.
More Information 
Make sure you check with your state insurance department about laws regarding health insurance claims. For more information about health, home, life and auto insurance options, and tips for choosing the coverage that is right for you and your family, go to www.insureUonline.org. 
July 2014
About the NAIC
  The National Association of Insurance Commissioners (NAIC)is the U.S. standard-setting and regulatory support organization created and governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer review, and coordinate their regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally. NAIC members, together with the central resources of the NAIC, form the national system of state-based insurance regulation in the U.S. For consumer information, visit insureUonline.org.