We understand how complex the healthcare delivery system is. Our process is designed to help simplify what is already a very complex and daunting system. We break each information down to a level of understanding for all our clients.
- The first step in advocating for medically necessary healthcare services is listening to each patient’s needs and asking the right questions that will help us better assist. This is typically done during the 1:1 consulatation phase.
- Once we have a good understand of each patient’s needs, we begin our review process. This typically involves a request of all notices received by each patient from their insurance company, and any other applicable information we need to determine the best course of action.
- Depending on the complexity of each situation, our review process could take somewhere from a week or more depending again, on the nature of each case.
- Upon completion of our review, we invite each patient and their caregiver back to discuss our determination, and our proposed step of action. This is followed up with an email summarizing our review and proposed step of action.
- For all cases where we determine that improper denial has occured, upon agreement by all parties, we begin to formulate a letter of appeal.
- Upon finalization of the appeal letter, we work with each patient and their caregivers in submitting the appeal and all supporting documents to the insurance company for their review.
- There are different timeframes for the review of appeal requests, as such, we work closely with each patient and their caregiver in: 1)tracking the progress of the appeal 2) ensuring that any information requested by the insurance company is reviewed by our team of experts, and responded to accordingly.
- If we are unsuccessful in getting the denial decision overturned, and we deem it necessary to escalate the request to the next level of appeal, our team of experts work with each patient in formulating a second level appeal request with either the: healthcare company, Independent Medical Review contractors as permitted by each State law, or request an appeal hearing with a State Judge.
- If necessary, we also work with the respective regulatory oversight body in getting the denial decision independently reviewed.
Our main focus is to ensure that the original improper denial decision is overturned as quickly as the patient’s health needs demand. Our team of experts are available during normal business hours, to answer any questions patients and their caregivers might have. In the event of an emergency, we do request the use of 911.