Tell me about a time you had to fight through the appeals process to secure coverage for a client—what was on the line and how did it resolve?
Answered by 8 licensed agents
As a licensed agent, I have not personally encountered an appeal process with a client. However, having worked in the medical healthcare field for 40 years, I have navigated numerous challenging situations and have advocated for my clients' best interests. I am pleased to share that I have successfully resolved over 60% of these appeals. The billing process can be complex, and I always recommend involving someone with my expertise and your healthcare provider when facing these types of challenges. The more expertise you have involved in the battle pulling for you, the more likely you are to win.
A client on a MAPD plan was denied coverage for a critical cancer drug her oncologist prescribed, labeled “not medically necessary.” We filed a Level 1 appeal with medical records—it was denied. We escalated to a Level 2 appeal, adding clinical studies, a peer physician letter, and a personal statement from the client. The Independent Review Entity reversed the denial, approving the drug with retroactive coverage. She began treatment within 10 days and saw improvement. This case underscored the power of persistence and strong documentation in the appeals process.
I once had a customer who was extremely upset about an issue with their plan. I listened attentively to their concerns and apologized for any inconvenience. Then, I offered them a thorough explanation of all parameters of their current plan, for which they were greatful.
Well most the time people are declined. They are declined for not meeting the guidelines for health issues after they've been out of their initial enrollment. Of 6 months
So therefore contesting anything is rare
The insurance companies make it very difficult
You have to provide medical records for typically up to 2 years. That would demonstrate whatever the supposed declined. Issue was is been resolved within the guidelines and you may need a letter from physician also
I had a client that was still within their open enrollment opportunity but Medicare said otherwise. I had to prove timeframes were incorrect in the system and that client could still get approved without underwriting. Client was already sick but would be covered once approved. It was resolved and client received coverage.
I had a client who lost her part B because she was out of work and in the hospital. No one tried to help her get her social security set up to maintain the premiums so she lost all coverage. She ended up moving states to where I live and got healthy enough to fight through the process of getting her social security set up and reinstating her part B. The process took so long but that by the time she got her new Medicare card with an updated Part B affective date, she missed her new enrollment windows and Medicare denied her enrollment. At this point she was spending over $400 per month on prescription drugs with no coverage and had been in and out of the Hospital, incurring significant financial burdens. I found a loophole due to her chronic health conditions and got her coverage with a carrier that specializes in managing care for her conditions. Medicare told us that she would have to wait until next year, but they were wrong and she now has the coverage and care she needs along with her prescription cost being lowered to less than $50/mo. That was a win.
