Insurance Company Disagrees With Your Doctor? Here's What To Do
In a perfect world, everyone would get along and no one would disagree about anything. Wouldn't that be lovely after an injury so you could focus on recovery? One of the worst possible times for disagreements is when someone is already struggling medically and financially due to an injury at work or in a motor vehicle accident. In the real world, the insurance company that is supposed to be covering your medical bills may disagree with your doctor. Here's what you would need to do.
Go through Qualified Medical Examination (QME)
If the insurance company disagrees with your medical doctor's evaluation of your condition and/or injury, they will require you to be examined by a qualified, independent doctor. This doctor must not have had any connection to you or your medical history whatsoever. He or she will give you a complete medical examination and review your medical history. His or her findings will be put into a transcribed report and sent it to the insurance company's adjustor. The adjustor will use the transcription to determine whether or not your claim meets the guidelines of the insurance company.
Get Evaluated by a Medical Specialist
To protect your interests, it's a good idea to get evaluated by a specialist at some point during this process, preferably before the insurance company sends you out for a qualified medical evaluation. Ideally, the claim you first submit to the insurance company should be completed by a specialist, if at all possible, instead of your primary care physician. If not, an evaluation of a specialist may help you appeal a denial of the claim.
For example, if an injury brought on the onset of traumatic myasthenia gravis, your claim would have a higher chance of getting approval if you were examined by a neurologist or a neurosurgeon. Yet, on the other hand, with a serious and complex condition such as this, a QME could be useful as a second opinion if they are also a medical specialist.
Throughout the process, you may have a nurse case manager assigned to your claim. Follow her directions as she does report back to the insurance company to inform them if you are being compliant with your medical orders and with following through with your treatment plans and appointments. This person is medically trained to recognize whether or not it is appropriate to seek appointments with various specialists for diagnosis, treatment, and/or care.
