Authorizations, Appeals, and Insurance Claims… Oh My!

It was such an honor to present at the 7th National ACHA Conference, and although I am happy to share the slides from my presentation on getting insurance to work with you, I want to summarize my presentation here.

The main message I want everyone to know is that insurance companies, like many people, do not understand congenital heart disease. Luckily, we have guidelines and will soon have medical board certification to help the insurance companies navigate our care – but they need a lot of education. Here are some tips on how you can set yourself up for success with insurance:

• When changing or adjusting insurance coverage it may be best to check with your insurance company, in addition to your ACHD program, to confirm which coverage is accepted.
• An ACHD cardiologist is a specialist; you may need a referral from either a primary care physician or a local cardiologist (pediatric or adult acquired heart disease cardiologist).
• Establish contacts—an authorization specialist, nurse coordinator, social worker, or billing specialist at both your ACHD clinic and through your insurance.
• Know your rights! Under the Affordable Care Act you have the following rights: 
  • Can’t be denied insurance on the basis of a “pre-existing condition,” but the insurance company has right to tell you where you can get care
  • Can stay on parents’ insurance up to 26 years old
  • Guaranteed right to appeal – both internal review and independent external review – and access to consumer assistance program.
  • Ends lifetime limits on coverage
  • Emergency care at any emergency room – they will treat without proof of insurance
• If you get denied – APPEAL! Insurance does not understand CHD, and many people are automatically denied without a proper review. An appeal process demands that review.
• Always notify your ACHD provider if you get denied for services or medications – they can help you fight.
• Know your resources:
  • Your insurance handbook or website
  • U.S. Department of Health and Human Services
  • The managed care division on your state’s website
  • ACHA for guidelines and advocacy 
  • The authorization and financial aid departments at your ACHD program.
• Use the ACHD guidelines and ask your ACHD program to use them to back up your request. Go ahead and print out the entire ACC/AHA guidelines for the management of adults with CHD; these will educate the insurance company (and FYI, the guidelines are set to be updated next year).

The sad truth is that in America the insurance companies have a lot of control. Just remember that you can advocate for yourself and educate those who try to deny you appropriate ACHD care. We have guidelines to support us, so don’t give up! There are many resources available to help you fight for the level of care you need.