Reimbursement Resource Toolkit
The Reimbursement Resource Toolkit was developed by Fibroid Relief to help uterine fibroid patients access focused ultrasound as their treatment of choice.
Individuals investigating what treatments are covered should first begin by contacting the phone number listed on the back of their insurance card. Customer service can refer you to information on specific policies, including requirements patients may need to meet before the focused ultrasound treatment can be approved (“pre-authorization”) requirements. Some patients may be able to access this information with a login and password on their healthplan’s website.
Q&A
Now what? My health insurance plan just denied my claim!
- Make sure you have a copy of your plan document and plan summary. Request them from your insurance company if you do not have copies.
- Information on how to appeal isusually includedwith the company's denial letter. If it's not, search the plan’s website, or call your health plan and request the information.
- File anappealwith your health plan quickly, as manycompanies place limits on how long appeals may berequestedafter a claim is denied.
- Modify ourtemplate letters(available in the toolkit) to appeal a denial or request information from your health plan.
- Ask yourhealth care providerto take action to support your case andwrite a letter to your health insurance plan.
I tried appealing, but my health plan is still denying my claim. Is there any hope?
- If you've exhaustedthe appeal process withwith your health plan, you may be eligible for an “external” or “independent” review. Specific information and instructions for applying to your state's review program can be found through theKaiser Family Foundation. Please refer to ourtemplate letterto request an external review.
Insurance: Tips and Resources for Appealing
Don't give up: persistence pays off. Be courteous and consistent in pursuing your appeal, and educate health insurance representatives about your case and uterine fibroids.
Document Everything:
- Request documentation of coverage decisions or policy information in writing from your insurance company.
- Keep copies of correspondence from your doctor and from yourself to the insurance company.
- Submit concerns to your employer's Human Resources department in writing (if applicable).
Take Notes:
- Record the names and job titles of the health insurance representatives you speak to and thetime and date of your calls.
- Keep a record of any conversations with your health care provider, employer, and state insurance commission regarding the denied treatment.
Seek Additional Support:
- Contact yourState Insurance Commissionand speak with a Consumer Advocate about your case.
Resources:
For more detailed information on appealing:
- Kaiser Family Foundation'sA Consumer Guide to Handling Disputes with Your Employer or Private Health Plan.
Appeal denied?Request anexternal review.
Insurance: How Your Doctor Can Help
Your doctor is your greatest ally when dealing with your health plan. Below are tips to enlist the help of your doctor:
1.Ask your doctor and/or treatment center to help with appealing the denial of a claim.Your doctor and his/her staff are best suited to explain your condition, your medical history and your treatment plan. If your claim for a treatment has been denied, ask your doctor to write a letter of medical necessity and/or to call your health plan provider as part of the appeal process.
2.Update your doctor on any health plan correspondence.Provide your doctor’s office or treatment center with documentation of all correspondence (including denial letters and notes from phone conversations) with your health plan. This will help keep your doctor or treatment center up-to-date on the status and details of your claim.
3.Provide your doctor with sample letters. Fibroid Relief has developed a sample letter for doctorsto use as a template when writing a letter to your health plan on your behalf.
5.Remember to thank your doctor or treatment center and his/her staff.Send a card or call the office to express your appreciation to him/her for working on your behalf. This little gesture can go a long way.
Letters for Patients:
- Sample letter for appealing the denial of a claim
- Sample letter requesting an external review by the state insurance commission
Letters for Health Care Practitioners:
- Sample letter appealing the denial of a claim (general)
Sample letter appealing ahealth plan denial - This letter is only an example.
[Today’s date]
Subject: [Name of patient]/Type of Procedure Denied (MRgFUS – Image Guided Acoustic Surgery)
[Name of medical director]
[Name of insurance company]
[Street address]
[City] [State] [ZIP code]
Dear [Name of medical director],
[Name of health plan] has denied my claim for Focused Ultrasound for treatment of uterine fibroids.
My physician, [name of prescribing physician], and I disagree with [name of health plan]'s ruling on my case. Please consider this letter a formal, written appeal of your denial of this necessary procedure. My physician is sending a letter documenting [his/her] recommendations for access to this treatment.
Symptomatic uterine fibroids have a significant impact on the quality of life for women. Uterine fibroids typically cause bleeding problems, such as heavy and painful menses, pressure symptoms (most often urinary frequency), and problems related to fertility and pregnancy.
Approved by the FDA in 2004, Magnetic Resonance (MR)-guided Focused Ultrasound (MRgFUS) is a noninvasive procedure based on the combination of real-time MR anatomic guidance, MR thermometry, and high-intensity Focused Ultrasound. Several hundred transducer elements become convergent at a point under MR guidance, leading to heating and coagulation necrosis.[i]
Focused Ultrasound therapy for fibroids has been shown to be a safe and feasible treatment for uterine fibroids.[ii] In a study conducted by Mayo Clinic, 97% of patients reported improvement of their symptoms 12 months following their treatment, with 90% rating their improvement either considerable or excellent.[iii]
[Describe in your own words your symptoms, treatment history, therapies you have tried, current symptoms and why this treatment should be covered]
Sincerely,
[Your name]
[Address]
[Phone number]
[Member identification number, Group code or other case record numbers]
CC:[Name of prescribing physician]
[Name of your insurance plan administrator at your work]
Tina Krall, Executive Director, Fibroid Relief
Page | 1
[i]Journal of the American College of Radiology2009 Jul; 6(7):510-3
[ii]Stewart EA, Gedroyc WM, Tempany CM, et al. Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique. Am J Obstet Gynecol 2003;189:48–54
[iii].K. Hesley, K.R. Gorny, D.A. Woodrum, D.L. Brown, K.R. Brandt, T.L. Henrichsen, J.P. Felmlee, N.J. Hangiandreou, Radiology, Mayo Clinic, Rochester, MN; B.S. Gostout, E.A. Stewart, Obstetrics and Gynecology, Mayo Clinic, Rochester, MN. Magnetic Resonance-guided Focused Ultrasound of Uterine Fibroids: Patient Follow-up 12 Months after Treatment, Presented at Society of Interventional Radiology 2010 Scientific Meeting
Sample letter to health plan on behalf of patient appealing a denial
This letter is only an example.
[Today’s date]
Subject: [Name of patient]/Type of Procedure Denied (MRgFUS – Image Guided Acoustic Surgery)
[Name of medical director]
[Name of insurance company]
[Street address]
[City] [State] [ZIP code]
Dear [Name of medical director],
I am contacting you on behalf of my patient, [Name of patient (Insurance ID #)]. [Name
of insurance company] has denied her claim for Focused Ultrasound for treatment of uterine fibroids. Please consider this letter a formal, written appeal of yourdenial.
Uterine fibroids are extremely prevalent, with nearly 70% of Caucasian women, and more than 80% of African-American women, developing fibroids by the time they are 50 years old.i Symptoms may include extensive bleeding, often causing anemia, pelvic pain and/or pressure and cramping, incontinence, sexual dysfunction, and reproductive difficulties and complications during pregnancy. ii
In my professional opinion, Focused Ultrasoundis the best treatment choice for [Name of Patient] [Explain the benefit/efficacy of the treatment to this specificpatient, and review patient’s treatment history including other treatments and contraindications to other therapies. Be sure to address how the patient meets any pre-authorization requirements or why an exception should be made.]
If you have any further questions regarding this patient, please do not hesitate to contact me.
Sincerely,
[Physician name]
[Physician address]
[City, State ZIP code]
[Phone number]
CC: State Insurance Commission
Name of patient
Tina Krall, Executive Director, Fibroid Relief
i. American College of Obstetricians and Gynecologists (2008). Alternatives tohysterectomyin the management of leiomyomas. ACOG Practice Bulletin No. 96.Obstetrics and Gynecology, 112(2, part 1): 387-399.
ii. AHRQ:Evidence Report/Technology Assessment: Number 34 Management of Uterine Fibroids, 01-E051, 2001
Sample letter appealing to the state insurance commission
This letter is only an example.
Specific instructions for applying to your state's insurance review program can be found on the Kaiser Family Foundation website at
Today’s date
Name of state insurance commission
Street address
City, State Zip Code
Dear Insurance Commissioner,
I have filed the attached insurance claim with [Name of insurance company] on [date of claim]. My physician has deemed this procedure medically necessary for my uterine fibroids; however, in spite of this my insurance company has denied me access to Focused Ultrasound.
I have had the following specific problem(s) with this insurance company:
1. Example: Name of insurance co. has refused to cover my physician prescribed treatment.
2. Example: My claim has been neither paid nor denied.
3. Example: Name of insurance co. has not acknowledged my request for a copy of their policy regarding the treatment my physician has prescribed me.
Please accept this letter as a formal written complaint against [Name of insurance company].
Sincerely,
[Patient Name]
[Patient Address]
[Phone number]
CC: HR Director at patient's workplace
Name of patient's physician
Tina Krall, Executive Director, Fibroid Relief