Humor me with this post. It deals with appeals.
Say your client Fred is really upset. He feels the prior authorization for his electric scooter should have been approved, but his Medicare Advantage carrier has denied it. It happens: Providers occasionally submit a weak authorization request and sometimes carriers might even make mistakes. When either of these happen, who do plan members like Fred turn to after a confusing conversation with customer service? He of course will call his insurance agent.
Back when I was young and foolish As a former carrier appeals supervisor, I know a few things about appeals. The following paragraphs assume you actually want to work with an appeal situation:
Start with customer service. A surprising number of issues might be resolved with a couple of calls. If your client isn’t comfortable on the phone or just can’t digest the information (this seems to be happening a lot recently), get on a 3-way call with him or her. Agents tend to be more attuned to customer service lingo.
If necessary you can help initiate step one in the process. An “organization determination” can even be done in advance to clarify if a procedure or service will be covered. If you have no luck with this, move to the more formal appeal process Level 1. A detailed overview of the steps through all levels of appeals is available here.
If your client is incapable of dealing with the process I suggest you become an unofficial advisor. Just note that carriers do not appreciate agents getting directly involved as the client’s representative in the formal appeal process unless you are a relative. It’s preferable that a client’s competent friend or family member become involved. You can coach the parties, but it’s not advisable that your agent name appear any documents. Your client can appoint a representative with a simple Form CMS-1696, which I’ve linked to right here. Include it with the rest of the appeal information.
I’ve utilized this form a few times on behalf of my older relatives who invariably buy their Medicare insurance from some other agent who does not return phone calls (We will deal with that type of unwelcome charity work in a future blog post).
For assistance with an appeal situation our affiliated agents can call me here at RBI. Just dial (800) 997 3107. I would not consider it charity work, so feel free to call or even email me.