Denial of Nursing Home Coverage

Robby Martin’s 82-year-old father, Jackie, faced continuous denial of coverage by one of the largest Healthcare providers in the USA after suffering a back fracture and requiring rehabilitation.

The Healthcare provider’s frequent denials of care led to Jackie’s premature death just days after the company terminated his nursing home coverage, pushing him to return home.

Robby battled the provider’s decisions through appeals but ultimately, the process exhausted Jackie, leading Robby to publicize his experience and engage in a lawsuit .

The lawsuit contends that the provider’s repeated denials were motivated by profits and influenced by an AI algorithm, prompting unethical practices that prioritize company profit over patient care.

How to avoid similar situation

To avoid situations where insurance companies deny essential healthcare coverage, individuals and families should take proactive steps to understand their policies, navigate appeals effectively, and advocate for their rights.

Here’s how to prevent and handle wrongful claim denials:

1. Understand Your Insurance Coverage

• Review Your Policy Carefully – Read your plan’s details to know what services are covered, including rehabilitation, long-term care, and hospitalization.
• Get a Written Coverage Explanation – Before receiving treatment, request a written statement from the insurer confirming what’s covered and under what conditions.
• Check the Role of AI in Claim Decisions – If the insurance company uses AI or automated systems to approve or deny claims, ask how decisions are reviewed and whether human oversight is involved

2. Obtain Pre-Approvals and Keep Records

• Request Pre-Authorization – For major medical services, submit a pre-approval request to your insurer before treatment begins to confirm coverage.
• Verify Coverage with Healthcare Providers – Work with the hospital, rehabilitation center, or nursing home’s billing department to ensure that services are approved before admission.
• Keep All Documentation – Save emails, approval letters, bills, and insurer responses in case you need to dispute a denial later.

3. Know Your Rights and Appeal a Denial Immediately

If coverage is denied, act quickly and appeal the decision:

Step-by-Step Appeal Process for Medicare Advantage Denials:

1. Ask for a Detailed Explanation of the Denial
   • Request a written denial letter explaining why coverage was denied.
   • Insist on a detailed reason, not just a generic statement.
2. File an Appeal with the Insurance Provider
   • Submit an appeal within the required timeframe (usually 30–60 days).
   • Include medical records, doctor’s recommendations, and any proof that the treatment is necessary.
   • Work with the healthcare provider’s billing office to submit supporting documents.
3. Request an Expedited Review if Needed
   • If the denial threatens the patient’s health or well-being, request a fast-tracked appeal, which must be decided within a few days.
4. Escalate the Appeal to an Independent Review
   • If the insurer denies your appeal, escalate the case to an independent third-party reviewer (such as a state insurance commission or a healthcare advocacy organization).
   • Some policies allow appeals through external arbitration or legal processes.
5. Seek Help from Patient Advocates and Legal Aid
   • Insurance Ombudsman or Consumer Assistance Programs – Many states and countries have consumer advocacy organizations that help policyholders dispute wrongful denials.
   • Legal Aid and Healthcare Attorneys – If your appeal is ignored or unjustly denied, seek legal assistance from professionals specializing in health insurance disputes.
   • Patient Advocacy Groups – Some non-profit organizations offer guidance and representation in insurance claim battles.
6. Push for Stronger Oversight and Consumer Protections

• Report Insurance Misconduct – If an insurer repeatedly denies medically necessary care, file a complaint with your country’s insurance regulatory authority or consumer protection agency.
• Advocate for Transparent Decision-Making – Insist that insurers provide clear, detailed explanations for claim denials and ensure human oversight in complex medical cases.

When an insurance company wrongfully denies necessary care, time is critical. By understanding coverage, seeking pre-approvals, appealing aggressively, and using patient advocacy resources, individuals and families can protect themselves from unjust denials and ensure they receive the healthcare they need.