Are “independent” medical reviews really independent?
In my role as a medical reviewer, I have overturned medical claims denied by insurance companies only to end up having wrestling matches with their medical directors who try to convince me to change my opinion. When I refuse to yield to their mental bullying, they find another reviewer who will give them the answer that they’re looking for. In the Brooklyn neighborhood that I grew up in, we would refer to such behavior as being “slimy” or lacking integrity.
Unfortunately, we live in an era where patients must become more proactive about their healthcare and not assume that the healthcare industry has your best interest at heart. Pregnant moms, this includes you. I can’t tell you how many times I had to fight for ultrasound approvals and authorizations for nonstress tests while an unborn baby faced the possibility of death. I described such scenarios in The Smart Mother’s Guide to a Better Pregnancy.
This is an exciting time because of advances in technology regarding healthcare but also a dangerous time because of the “business” of healthcare. Prenatal genetic screening is extremely helpful because it identifies potentially harmful genes that could be passed on to your unborn child. Genomics is the study of why certain genes caused medical conditions such as heart disease, etc. Although these tests are expensive, they can save human life or help a family make life-altering decisions. These are the tests that many insurance companies reject.
What should a pregnant woman do to reduce the chance of receiving denied claims by an insurance company?
1. Try to get advance insurance authorization before consenting to have a procedure or a test
2. If your claim is denied, ask for an “independent medical review”
3. If the independent review maintains the denial, ask to speak with either the medical reviewer who made the decision or insurance medical director and if you’re still unhappy with the decision, ask for a second review
4. If none of the above work, use the power of social media to write a public review about your situation. There may be other women who face similar problems or conditions
Sometimes fighting on behalf of your children begins before they’re even born.