I read a great article in Smart Money about how to advocate against your insurance company. These same strategies will work for advocating against the state at a fair hearing. They are simple and easy.
1. Write a detailed letter of why the procedure, therapy or medicine should be covered. Mark sure to include studies or articles that support your argument. IF you can, include a letter of medical necessity from your physician and other professionals who could speak to this need.
2. See another physician or therapist to get a second opinion. If this physician agrees have them write a letter of medical necessity as well. Consider asking your first physician to referred you for the second opinion.
3. Stay calm and keep a journal. Document every time you speak to someone, who they are, where they are from and what they said. Fight to have your physician on the phone speaking directly to the medical director of your insurance company.
4. Read your policy and look for loop holes that can help you get something approved. It is important to know what your policy says as they are all different. This is especially important when dealing with the state as most state employees do not know their own policy and misquote it often.
So let me give you a couple of examples on how this would work. The first example will be the state denying a second hour of speech or decreasing speech hours by half. This is what I would do:
1. Evaluate honestly if your child really needs the hours and what you hope your child will gain from the hours. Do research to validate your need for the hours and what goals and skills will be gained with those hours.
2. Get the primary care physician to write a script for the hours and ask the physician to give you a letter of medical necessity. you can draft one for him and give it to him so that most of the work is done for him.
3. Contact your developmental pediatrician and have them write a letter of medical necessity or report explaining why the service is needed.
4. Contact the speech therapist and have her write a letter of medical necessity and a list of goals that will be worked on with the hours additional hours.
5. Contact the occupational therapist and teacher at school (or any other professional who may be helpful) and see if they will write a letter of support for the additional hours or the need to keep the hours.
6. Write a detailed list of why your child needs these hours. What goals will be addressed and how this will affect the life and well being of your child.
7. Submit all of this in your appeal.
8. It is quite likely that your appeal will be denied. File for a fair hearing. Believe it or not only half the parents decided to go to fair hearing. Most cases are settled at the hearing right before it starts. The state believes it is better not to settle until the day of the hearing and the numbers bare that our. Be sure to always ask for fair hearing.
9. If you go to fair hearing try to get your pediatrician and therapist to testify over the phone.
10. If your insurance company is the one denying you will want to have your doctor speak with the medical director and yourself.
Good Luck!
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