• Mon. Jun 27th, 2022

Care Corner: Appealing Aggravation

By Dr. Tyra Oldham

Tyra Oldham. Photo provided

In the care process, it comes a time when an insurance company will deny service(s) for your loved one. The issue is that the insurance company fails to recognize the concerns you realize as the caregiver. The struggle is to convince the insurance company and Medicare that the care requirements are necessary within the bundled solutions within the plan.

The appeal process is short but daunting, and the ability to remain calm despite the urgent and emergent needs of your loved one. What is so surprising is direct care is not as challenging as the responsibilities for another’s care. The responsibility of economics, insurance, and management of it can lead to caregiver burnout. This article will focus on the role of insurance in caregiver life.

The nature of insurance is to pay for the probability of use in the future. It is that future that is important when it becomes present to collect on the previous payments for services today. Moreover, when ill, the direct or indirect services and how they are allocated are the difference between recovery.

Next, there is always the carrier’s potential for no care as an alternative solution. Sometimes the requested care is not granted, and the insurance company offers lower care services as an alternative. When the care demanded is not given, the option for the caregiver or the person with a power of attorney (POA) is to appeal.

The appeal takes ten-fifteen minutes, but the energy, focus, and communication required can be stressful. In the appeal, the wording on the patient care is vital to expressing the needs of your loved one to the appeals representative. This information is then pushed up the chain to a third-party doctor to approve or deny the claim. During the three days, you await an answer for the next steps. The caregiver is not given much time to act, so have an alternative plan of action. Care Corner is a great place to share some appealing tips.

  1. To appeal do your homework. Do not take this quick process as something to be under-considered. Be mindful of your loved one’s need for services during the appeal process.
  2. Get all the relevant short-term historical facts and records.
  3. Remove the emotion. The agent you speak to is not the enemy. Be pleasant when communicating; it makes the process easier for all.
  4. State the reasons for the appeal thoroughly and convincingly.

If your insurance company approves your appeal, you are on your way in the short term. Be prepared for the next step because the approval does not always mean long. If your request is declined, the next step is to accept or appeal again. When appealing, you are now sharing the same or more information with Medicare. If Medicare disapproves, the next step is to appeal for a hearing through an Administrative Law Judge (ALJ). The ALJ is a formal hearing with a judge from Medicare. The ALJ will provide the appellant with a judge of record and a hearing date.

In the end, the caregiver must weigh the health services for the care against the time, stress, and emotional health that the caregiver will face. For me, I have always appealed. I always fight for my mom’s care, but it does take its toll.

For more information on care support and caregiving advice, write or email the “Care Corner.” Want to discuss care? Care Corner is that place to talk care, address questions for current and potential caregivers, and provide suggestions on agencies, services, and tips to assist in a care journey. (Read more of the article from the Herald Newspaper– subscribe now

The Care Corner is for everyone, no matter their age or process in care. For more information on caregiving, send your questions to Care Corner at the Cincinnati Herald or via email at care@carecorner.info.