Sapoznik Insurance, A World Company

What to do if your recommended treatments are denied by insurance

Having treatments or claims denied by the insurance company happens far too often. Some people try to fight it on their own, which can seem like an endless battle, while others who are more fortunate tend to pay for the treatment out of pocket and figure it out later. There is a third option, which is to have an advocate help you handle the process. At Sapoznik Insurance, a World Company, we are dedicated to supporting our clients. If a claim is denied or a treatment recommended by a doctor is altered, we are there to assist. Herein lies the difference between an ordinary insurance broker and a client-centric one.  

Physical therapy (PT) helps patients in many phases of healing, from initial diagnosis through the restorative and preventive stages of recovery. It is an important aspect to a holistic approach to healing. Physical therapy may be a standalone option, or it may support other treatments. Unfortunately, it is limited under insurance contracts, and it also requires coordination between the carrier, the carrier vendor which is a third-party administrator who authorizes the services, and the Orthopedic doctor. Many times, it becomes complicated, time consuming, and extremely frustrating. 

The injury  

This case was a 60-year-old female who fell at home, breaking several parts of her body. She was hospitalized and then taken to rehab to help her regain her strength and obtain mobility. She was then sent home to continue receiving therapy at an outpatient PT center. The PT facility had sent the doctor’s order to the carrier for approval, and within three days, was told they approved three sessions at an outpatient facility. However, the doctor had ordered six to eight sessions and wanted to reassess her condition to determine whether additional sessions would be required. 

Imagine falling in your home and breaking both elbows, one wrist, fracturing a shoulder, and an ankle, rendering you immobile, then having your insurance carrier deny much-needed PT sessions. Now the same insurance carrier is telling you that you must visit an outpatient facility, the nerve. 

The situation  

Early Sunday morning, we received emails and text messages from the Deputy Director of Human Resources. She was distraught and frustrated regarding the situation with her employee. The carrier was limiting the PT sessions and overriding the doctors’ orders. Aside from the discrepancy in the number of sessions, the carrier wanted the employee to receive the services at a facility and not at home. The patient could not move, much less drive. Our client was outraged by the lack of response from the insurance carrier and the disconnect between the PT and the carrier. The truth is these transactions take time to coordinate, especially with so many parties involved. However, these delays cause frustration, anxiety, and concern for the patient who already is not feeling well. Our client was rightfully anxious about the well-being of her employee.  

There was a significant discrepancy between the number of sessions the doctor ordered, what the facility could do in-house, what needed to be referred out, and what the carrier was willing to approve. It took approximately two weeks to gather the information required by the insurance carrier to provide an authorization form for the additional therapy sessions and to coordinate treatment. This meant working with two different therapists and ensuring the prescriptions for each had the specifics of what needed to be done. I had daily calls with all the providers involved to expedite this and communicated with our client daily to provide updates on where we were in the process.  

The resolution 

We worked to get the employee the additional therapy sessions the doctor initially ordered. This was done by obtaining the medical notes from the orthopedic doctor and soliciting a peer-to-peer consultation between the orthopedic doctor, the PT facility, and the insurance carrier to discuss her complicated case. Approval was received for a certain number of PT sessions at the facility and some at home. The member was thankful that we had stepped in to coordinate this and relieve her of the stress she was experiencing.

This situation is common and having the right team in place is critical. The last thing you want to deal with during a medical issue is paperwork and a never-ending cycle of phone calls; that is where the Sapoznik team can help.

While you focus on getting better, we focus on getting the appropriate care approved.

Written by Mercy Perez, Senior Client Manager at Sapoznik Insurance, a World Company