What to do if your health insurer denies a claim
 
That was the focus of Susan Prest's and Dr. Barbara Center's talks. Many medical claims for reimbursement by insurers are denied or reduced, but there is a good chance of getting that decision reversed.

Susan told us a bit of her background in clinical psychology and in staffing patterns for mental health care. She saw a need and created a firm to review disputed claims and billing in treatment of mental health and substance abuse cases. And happily for us, she moved it to Madison. The business has grown to involve review of 30,000 cases and to serve 130 insurance firms and 32 State Depts. of Health or Depts. of Insurance.

Few people know their rights are and few appeal their denials. Susan urged that if denied, be patient, follow the instructions for appeal, and expect that the denial will be repeated, perhaps three times. The insurer may only read the summary of MD notes, not the full record. Continue to press the appeal to the state level. The insurer may settle at that point because it doesn't want the work and bad publicity. State review, with the detailed work and recommendations often carried out by Prest Co., finds in favor of 60% of the cases that reach that level. Increasingly, some of the 40% are carried on to trial, a growing part of the business, Overall, though, and sadly, only 1 in 20 patients even try for review.

Dr. Center supervises a large staff of MDs worldwide. She picked up the thread to tell how the 50 specialist MDs on staff are trained to do these reviews. They must be unbiased, careful, thoughtful, collegial. Increasingly there are accepted standards for treatment. These help all. The reviewing MDs examine the health plan, the state's requirements, the patient's record, and standards for treatment of the diagnosis. These reviews may be sought by insurance firms or by states

The talks stimulated many queries. Thank you Susan and Dr. Center. Come back again.