What are your Options if Insurance Won’t Cover Your Transitional Care?

Getting the right care for yourself or a loved one starts with knowing your options, but unfortunately, insurance and financial issues can sometimes limit your healthcare options. Luckily, there are things you can do if you or a loved one needs transitional care and your insurance won’t cover it, and today’s discussion will outline your options and the steps you can take to get your transitional care insurance.

Step One: Know Your Rights as a PatientHealth Insurance - Folder Register Name in Directory. Colored, Blurred Image. Closeup View..jpeg

Knowing your rights can completely change the outcome of a situation. For instance, did you know insurance companies have to provide you with a reason if they deny a claim? There are four main reasons why a company would deny a transitional care insurance claim, and they may say:

  • The care or treatments involved were experimental
  • The care isn't medically necessary
  • It doesn’t meet the standard of care
  • The resident wasn’t improving

Step Two: Appeal

This is arguably the most important thing you can do if your insurance won’t cover transitional care (but you do have to find out the reason for denial before you can proceed). The letter of appeal doesn’t have to be extremely long or complicated, but it does have to contain some relevant information, including:

  • Contact information
  • Subscriber number
  • Case reference number
  • Diagnosis and procedure codes
  • Hospital, doctor, and transitional care unit information

Just make sure the appeal is filed correctly every step of the way, or the transitional care insurance may be denied because of that alone.

Step Three: Be Ready to Make Your Case

The wording and argument of your appeal should be guided by the reason for the initial claim denial. For instance, if the claim was denied on the grounds that it wasn’t medically necessary, then you're going to have to come up with reasons why it is. And don’t be afraid to do some research and back up your argument with some statistics and facts.

In order to do this successfully, you're probably going to have to provide some background information about you or your loved one and the circumstances leading to the need for transitional care. Lastly, make it clear how you or your loved one will be affected if he or she cannot get the care required.

Step Four: Get Your Healthcare Providers on Board

To provide the most comprehensive and persuasive appeal letter, you'll have to work with your or your loved one’s healthcare providers, including doctors, nurses, and TCU staff. For one, it’s important for them to know what's going on so they can continue coordinating ongoing care, but they may also be able to help explain why the transitional care is necessary and to show how you or your loved one has or will improve with the right care.

The transitional care management team at Walker Methodist will be happy to provide you with any relevant information we can to help you with the appeal process. If you're in the planning stages of your own or your loved one’s transitional care and know in advance that your insurance company doesn’t cover it, look into whether specific healthcare institutions or housing options can be covered instead. And if you need to request any TCU or rehab information from Walker Methodist, we’re always here to help.


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Topics: Care and Programs

Chris Turner

Written by Chris Turner

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