Insurance Tools for Providers and Disease Organizations

Patients Rising provides expert advice to providers and disease organizations in dealing with insurance companies.  Advocating for patients can be a frustrating and time-consuming process.  We provide free in-person and web-based education on how to make this process easier and more successful.  

Take a look below at some of our tips for dealing with important topics like fair payment, medical necessity, peer reviews and out-of-network issues.  We also connect patients who have chronic or life threatening diseases with personal advocates who can expertly and quickly navigate the insurance process. Feel free to contact krego@patientsrising.org for more information.

Why to Seek Help From a Professional Advocate

Providing or advising about a treatment is very different than getting coverage and payment for it. Providers and their staff get frustrated by the time spent dealing with insurance instead of patient care.

Tips For Getting an Insurer’s Attention

Insurers provide very little training, audits or oversight to employees. The business model relies on the fact that frustrated providers and patients will just give up on requests.

Tips for Medical Necessity Documentation

Making a good argument for coverage of medically necessary treatments requires planning and follow through. Good arguments up front can prevent lengthy and time consuming appeals later. 

Tips for Getting a Fairer Physician Medical Necessity Review

Internal and external physician reviews are the principal way in which requests for medically necessary services are denied. Insurers game the system by choosing unqualified and conflicted reviewers, but there are strategies for getting a fairer review.

Tips for Working With Self-Funded Plans

Over 65% of people get insurance through a self-funded employer plan. This means the insurer is the administrator and the employer pays the claims. State insurance law protections don’t apply and the insurer can apply their own policies to restrict new or expensive treatments.

Tips for Out-of-Network Requests

Going out-of-network can result in significant costs for the enrollee but is often necessary to ensure the best outcome.

Tips for Unproven, Experimental or Investigational Treatments

A common reason for denying treatments is that they are unproven, experimental or investigational. Address these issues with careful attention and good strategy.

Tips for Obtaining Fair Payment from Insurers for Covered Services

Even if a service is covered, an insurer can deny payment or pay so poorly that it’s basically denying the service

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