Ali Ingersoll has waged war on the insurance industry so many times she’s almost starting to have fun doing it.
She never enjoys the dozens of hours she spends gathering paperwork, sitting on hold, or slashing through the thicket of rules and regs that govern insurance appeals. But when you go through all that and gain approval for whatever the insurer has spent weeks, months, or years denying, it’s supremely satisfying. And Ingersoll has perfected the art.
In her most recent triumph (detailed in a series of articles at PUSHLiving), Ingersoll bumfuzzled her insurance company so thoroughly that they ended up overruling their own “final denial” rather than slug it out with her through another round of appeals. And she’s got a simple message for every amputee who’s ever been denied coverage for a prosthetic device, pain treatment, mobility aid, or other medically necessary equipment or procedure: “No” is never a definitive answer. It’s just another wall you have to tear down on the way to “yes.”
“I’ve been through this many times,” says Ingersoll, “so I know how to navigate the system by now. But most people don’t. There are clear-cut steps, but it takes whole lot of time to learn them and to follow them. The whole thing is designed to discourage people. It shouldn’t be this hard, but it is. It’s what I and tens of thousands of people with disabilities constantly have to go through just to survive.”
Ingersoll is a quadriplegic, not an amputee, but insurance companies don’t discriminate among different classes of patients—they send the same form-letter denials to everyone. All individuals, amputees included, can profit from Ingersoll’s methods of holding insurers to account, and she’s committed to helping anybody who asks.
“A successful life to me means paying it forward at every turn,” she says. “There are millions of injustices going on in the world every second of every day. We must care for each other and fight for each other. I’ll always continue to fight my battles, but I’m also willing to help others fight their own personal health insurance battles.”
Read Ingersoll’s whole story over at PUSHLiving. If you’re contending with an insurance denial and you’re not sure where to get started, reach out to her at [email protected] Or just follow her strategies for success in the insurance wars:
1. Study the terrain before you step onto the battlefield.
The biggest thing insurers have going for them is confusion. They know the landscape because they created most of it, and the parts they didn’t create were shaped by their lobbyists and government allies. The rules vary depending on whether you’re covered by private insurance or a public program (such as Medicare or Medicaid), which private insurer(s) carries your coverage, what state you live in, and a host of other factors. In general you’ll file your initial appeal(s) directly with the insurer, but once those fail (and they usually do) you usually have the right to appeal to an eternal party. Nail down all of this information before you start—the whole sequence, from initial claim through final appeal. Know who’s involved, how long each step takes, and what rights and responsibilities you have. Equip yourself with the knowledge to think two or three steps ahead and anticipate the next move. To repeat: the insurers’ biggest advantage is their customers’ lack of awareness. Take that advantage away from them.
2. Know thine enemy.
When you send in a claim or file an appeal, your insurer has it reviewed by a panel of health care professionals that may include doctors, nurses, lawyers, and medical coders. These are the individuals who determine whether the coverage you seek meets the definition of “medically necessary.” If you’re denied, you have the right under federal law to obtain the names and credentials of every person who was involved in the decision. “I made this request in my most recent case,” Ingersoll says, “and sure enough, none of them had expertise related to spinal-cord injuries. Usually your panel is made up of general practitioners, maybe a rehabilitation therapist of some kind, but they’re not specialized.” If the reviewers lack the qualifications to judge your case fairly, you have a right to know. Ask to speak with the insurance company’s HIPAA-compliance/privacy officer.
3. Rally your allies.
When an insurance company determines that an element of your care isn’t medically necessary, that isn’t just an affront to you. It also overrules the professional judgment of whatever health care professional prescribed the care in the first place, be it your prosthetist, physical therapist, primary care doc, or whomever. Denial of coverage interferes with their practice and dilutes their outcomes. It also hurts the bottom line of any third-party medical providers or suppliers who are involved in the care. All of these stakeholders have a selfish interest in getting you covered, so don’t be shy about bringing them aboard. They’ll advocate for you not simply as a favor, but as a matter of sticking up for their own interests.
4. Slay them with kindness.
“My approach is to be pleasantly persistent,” says Ingersoll. “I might be so frustrated I have to swear when I get off the phone. But while I’m talking with anyone, I don’t raise my voice and I don’t let my anger show.” When you let your emotions intrude, it helps the insurer portray itself as a fair and reasonable party that’s impartially applying the rules. In reality, you’re the one with the reasonable claim. You’re the one with patient-focused medical specialists backing you up. Have confidence in that position and let it calm you. The more you maintain your cool, the better your odds of prevailing in an external appeal.
5. Call in air cover.
The tipping point in Ingersoll’s most recent case occurred when she finally took her grievance to an investigative TV reporter. The station aired a segment on Ingersoll’s case, contrasting her persistent and thoroughly documented claim against the insurance company’s comparatively weak justifications for denial. The bad publicity did the trick: Ingersoll had already filed an appeal with the state insurance board, but before the hearing even took place her insurer contacted her with the welcome news that—contrary to their own repeated determinations that her claim wasn’t medically necessary—her device would be covered after all.
“When I received the call,” Ingersoll writes, “I was elated and infuriated at the same time. Why the hell do I have to fight so hard when I pay nearly $13,000 a year for private health insurance to receive medically necessary equipment? What about all of those folks who don’t have the energy, the time, the know-how, or the support system to push as far or as hard as I have?”
Ingersoll is looking into the possibility of establishing a nonprofit whose sole mission would be to help disabled people navigate the appeals process and overturn unjust insurance denials. If you want to help her get this initiative off the ground, contact her at [email protected]